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INTRODUCTION

Gastrointestinal bleeding (GIB) presents as either overt or occult bleeding. Overt GIB is manifested by hematemesis, vomitus of red blood or “coffee-grounds” material; melena, black, tarry stool; and/or hematochezia, passage of red or maroon blood from the rectum. In the absence of overt bleeding, occult GIB may present with symptoms of blood loss or anemia such as lightheadedness, syncope, angina, or dyspnea; with iron-deficiency anemia; or a positive fecal occult blood test on colorectal cancer screening. GIB is also categorized by the site of bleeding as upper, from the esophagus, stomach, or duodenum; lower, from the colon; small intestinal; or obscure GIB if the source is unclear.

GIB is the most common gastrointestinal condition leading to hospitalization in the United States, accounting for ~513,000 admissions and $5 billion in direct costs annually. The case fatality of patients hospitalized with GIB is ~2% in the United States. Patients generally die from decompensation of other underlying illnesses rather than exsanguination.

SOURCES OF GASTROINTESTINAL BLEEDING

Upper Gastrointestinal Sources of Bleeding

PEPTIC ULCERS

Peptic ulcers are the most common cause of upper GIB (UGIB), accounting for ~50% of UGIB hospitalizations. Features of an ulcer at endoscopy provide important prognostic information that guides subsequent management decisions (Fig. 48-1). Approximately 20% of patients with bleeding ulcers have the highest-risk findings of active bleeding or a nonbleeding visible vessel; one-third of such patients have further bleeding that requires urgent surgery if they are treated conservatively. These patients benefit from endoscopic therapy such as bipolar electrocoagulation, heater probe, injection therapy (e.g., absolute alcohol, 1:10,000 epinephrine), and/or clips with reductions in bleeding, hospital stay, mortality, and costs. In contrast, patients with clean-based ulcers have rates of serious recurrent bleeding approaching zero. If stable with no other reason for hospitalization, such patients may be discharged home after endoscopy.

FIGURE 48-1

Suggested algorithm for patients with acute upper gastrointestinal bleeding based on endoscopic findings.

Randomized controlled trials document that high-dose, constant-infusion IV proton pump inhibitor (PPI) (80-mg bolus and 8-mg/h infusion), designed to sustain intragastric pH >6 and enhance clot stability, decreases further bleeding and mortality in patients with high-risk ulcers (active bleeding, nonbleeding visible vessel, adherent clot) when given after endoscopic therapy. Meta-analysis of randomized trials indicates that high-dose intermittent PPIs are noninferior to constant-infusion PPI therapy and thus may be substituted. Patients with lower-risk findings (flat pigmented spot or clean base) do not require endoscopic therapy and receive standard doses of oral PPI.

Approximately 10–50% of patients with bleeding ulcers rebleed within the next year if no preventive strategies are employed. Prevention of recurrent bleeding focuses on the three main factors in ulcer pathogenesis, Helicobacter pylori, nonsteroidal anti-inflammatory drugs (NSAIDs), and acid. Eradication of ...

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