QuestionSBA
QuestionChoice
Boerhaave's syndrome is caused by perforation of the oesophagus. It can also be caused by vomiting and retching; however the patient would be much more unwell as this is a life-threatening condition. Pain, dysphagia, massive haematemesis, haemodynamic instability and surgical emphysema are much more typical features of Boerhaave's syndrome. Given how well this patient is, Mallory-Weiss tear is a much more likely diagnosis
33592
e
Boerhaave's syndrome
QuestionChoice
One of the complications of peptic ulcer disease is an upper GI bleed. Peptic ulcer disease can present in young adults, with causes including alcohol, H. pylori infection and regular NSAID use. However, given that vomiting and straining are typical causes of a Mallory-Weiss tear, this patient is more likely to be presenting with a Mallory-Weiss tear
33590
c
Peptic ulcer disease
QuestionChoice
One of the complications of oesophageal cancer is an upper GI bleed. However, it is exceedingly rare for a 22-year-old to develop oesophageal cancer, especially in the absence of any specific risk factors in the history
33591
d
Oesophageal cancer
QuestionChoice
A Mallory-Weiss tear is caused by tears in the oesophageal mucosa. This is typically caused by vomiting and retching, increasing the pressure at the gastro-oesophageal junction. This typically presents with haematemesis or blood-stained vomitus in the presence of vomiting or retching. In this case, this is on a background of acute alcohol intoxication leading to excessive vomiting. These patients will typically have a normal examination/examination in keeping with the cause of vomiting, although there can be haemodynamic instability if a significant amount of blood is lost. The majority of patient resolve spontaneously with no complications. All patients with an upper GI bleed should receive oesophagogastroduodenoscopy, with urgency based on clinical presentation and Glasgow-Blatchford score
33588
a
Mallory-Weiss tear
QuestionChoice
Oesophageal varices are enlarged veins that develop due to portal hypertension. These can rupture, leading to life-threatening upper GI bleeds and are generally associated with cirrhosis. This patient is relatively young, so is unlikely to have developed cirrhosis at the age of 22. They also have no features of chronic liver disease on examination. Although alcohol is a common cause of cirrhosis, there is no evidence this patient has chronic harmful alcohol use or alcohol dependency. It is more likely that this patient was acutely intoxicated with alcohol
33589
b
Oesophageal variceal bleed
Concept
Chapter
# Summary
 
An upper gastrointestinal bleed (UGIB) is a common emergency presentation, with the main symptoms being haematemesis, coffee-ground vomiting and melaena. Haemorrhage can be anywhere in the oesophagus, stomach or duodenum and common causes include peptic ulcer disease, variceal bleeding, Mallory-Weiss tears and angiodysplasia. Management involves resuscitation with IV fluids and blood products, and identification of the likely cause which may be treatable via an endoscopic approach. 
 
# Definition
 
An UGIB is defined as any haemorrhage of the gastrointestinal tract between the oesophagus and the duodenum at the ligament of Treitz (the anatomical landmark that differentiates upper from lower GI bleeds).
 
# Epidemiology
 
- Acute UGIB is a common medical emergency, accounting for 50,000-70,000 admissions to hospital in the UK per year
- In hospital mortality is approximately 10%
- Older patients and those with comorbidities are more likely to experience higher morbidity and mortality than young fit patients with more physiological reserve
- Men are more affected than women
- The most common cause identified is peptic ulcer disease
 
# Aetiology

**Bleeding from the oesophagus:**

- **Oesophageal varices:** usually secondary to portal hypertension due to hepatic cirrhosis
- **Oesophagitis:** inflammation may be due to gastro-oesophageal reflux, infections (especially in immunocompromised patients), or medications such as bisphosphonates
- **Mallory-Weiss tear:** longitudinal mucosal lacerations that occur after severe vomiting or retching
- **Oesophageal cancer:** friable blood vessels in the tumour may cause chronic or acute bleeds
 

**Bleeding from the stomach:**

- **Peptic ulceration:** usually secondary to Helicobacter pylori infection or chronic NSAID use
- **Gastric varices:**: also associated with portal hypertension
- **Gastritis:** may be due to H. pylori infection, NSAIDs, alcohol or stress-related mucosal inflammation
- **Gastric cancer:** tumours may ulcerate or erode blood vessels
- **Vascular malformations:** a Dieulafoy lesion is a dilated submucosal artery that erodes the gastrointestinal mucosa resulting in massive bleeding
 
**Bleeding from the duodenum:**

- **Peptic ulceration:** as per ulceration in the stomach
- **Aortoenteric fistula:** a rare but life-threatening condition where an abnormal connection forms between the aorta and the gastrointestinal tract, usually following abdominal aortic aneurysm repair

# Classification

There are two main scoring systems used to classify patients as high or lower risk:

- The Glasgow-Blatchford score is used as an initial assessment to determine how urgently endoscopy is indicated
    - It takes into account haemoglobin, urea, systolic blood pressure, tachycardia, melaena, syncope, heart failure and liver disease
    - Patients scoring 0 are considered to be low-risk and may be discharged for an outpatient OGD        
-  The Rockall score can be calculated both pre and post-endoscopy but NICE recommends using it post-endoscopy to help with risk stratification
    - The following table shows how this is calculated (with only the first three parameters used in the pre-endoscopy scoring)
 

 |  | 0 points | 1 point  | 2 points  | 3 points  |
 | ----------------------------------------- | ------------------------- | ------------------- | ---------------------------------------------------------- | ------------------------------------------ |
 | Age (years)  | <60  | 60-79  | >80 | |
 | Systolic blood pressure/pulse rate (mmHg) | SBP>100, HR<100  | SBP>100, HR>100  | SBP<100 | |
 | Comorbidities  | None |  | Ischaemic heart disease or cardiac failure | Liver failure, renal failure or metastatic cancer |
 | Post endoscopy diagnosis | Mallory-Weiss tear | All other diagnoses | Upper GI malignancy | |
 | Signs at endoscopy | No blood or dark red spot |  | Blood in upper GI tract, spurting vessel or adherent clot |
 

# Signs & Symptoms

The most common symptoms are **haematemesis** (vomiting blood) which is seen in 50% of patients, and **melaena** (black, sticky and tarry stool) which is seen in 70%.

Other symptoms include:

- "Coffee-ground" vomiting (dark digested blood)
- Lightheadedness
- Syncope
- Abdominal pain
- Symptoms of anaemia in subacute or chronic bleeds
    - Fatigue
    - Shortness of breath
    - Decreased exercise tolerance
    - Palpitations
        
Signs include:

- Tachycardia
- Hypotension
- Prolonged capillary refill time
- Altered mental state
- Abdominal tenderness
- Melaena or haematochezia (fresh red blood) on rectal examination
- Stigmata of chronic liver disease in patients with cirrhosis, e.g.
    - Spider naevi
    - Gynaecomastia
    - Palmar erythema
    - Caput medusae

# Investigations
         
**Bedside tests:**

- **Venous blood gas** to obtain urgent haemoglobin, lactate may be raised if shocked
- **ECG** as cardiac ischaemia may complicate haemorrhage (type 2 myocardial infarction), screen for arrhythmias if tachycardic

**Blood tests:**

- **Full blood count** for haemoglobin (note that there may be a delay in this falling due to haemoconcentration so do not be falsely reassured if normal)
- **U&Es** - classically urea is disproportionately raised due to digestion of blood
- **LFTs** to screen for liver cirrhosis (increased risk of variceal bleeding)
- **Coagulation screen** so that abnormalities might be corrected to reduce bleeding
- **Group and save** in case blood transfusion is required
- **Cross-match** so that matched blood can be given when needed


**Imaging/special tests:**

- **Oesophago-gastroduodenoscopy** (OGD) 
    - Also referred to as an upper GI endoscopy
    - Usually the definitive diagnostic test to look for a cause of bleeding
    - Allows risk stratification with the Rockall score
    - Facilitates endoscopic treatment (see Management section)
- **Chest X-ray** to look for evidence of aspiration or perforation (e.g. pneumomediastinum or free air under the diaphragm)


# Management
 
**Resuscitation:**

- Take an A to E approach as in any medical emergency and activate the **major haemorrhage protocol** for any significant bleed
- Consider if **airway support** required (e.g. in an unconscious patient) and position to reduce aspiration risk if ongoing vomiting
- Ensure adequate **IV access** (2x wide bore cannulae in the antecubital fossae ideally) and take urgent bloods including a blood gas
- **Resuscitation** with IV fluids and/or blood 
    - Give a **fluid bolus** if unstable
    - In a massive bleed follow local transfusion protocols
    - **Transfuse red blood cells** if Hb < 70, targeting a Hb of 70-100
    - Consider transfusion at a higher Hb in patients who are unstable or have ischaemic heart disease
    - **Transfuse platelets** if these are below 50 
- **Correct any coagulopathy** or **anticoagulant** medication (may require haematology input)
- In suspected variceal bleeds, give **terlipressin** and **prophylactic antibiotics**
- **Immediate endoscopy** is required in severe UGIB; all other patients should have an endoscopy within 24 hours of admission
    - Non-variceal bleeds can be treated mechanically (e.g. **clipping**), with **thermal coagulation** or with **fibrin or thrombin** (plus adrenaline)
    - Oesophageal variceal bleeds should be treated with **band ligation**
    - Gastric variceal bleeds should be treated with N-butyl-2-cyanoacrylate injections (**sclerotherapy**)
- **Proton pump inhibitors** (PPIs) should **not** be given prior to endoscopy - if the OGD shows a non-variceal UGIB with stigmata of recent haemorrhage (e.g. a peptic ulcer) high-dose IV or PPIs should be started
- **Review medications** with associated bleeding risks
    - Hold DOACs
    - Hold warfarin
    - Hold P2Y12 inhibitors (e.g. clopidogrel, ticagrelor) - discuss with cardiology if the patient has coronary artery stents 
    - Aspirin can be continued
        
        
# Complications

- **Rebleeding** is a major complication which can occur after endoscopic therapy
    - Repeat endoscopy should be offered +/- endoscopic treatment
    - Patients may require additional treatment to stop bleeding which may be via an interventional radiology or a surgical approach 
    - Options for varices that continue to bleed include Sengstaken-Blakemore tube insertion (a bridging therapy) or a transjugular intrahepatic portosystemic shunt (a definitive treatment to reduce portal pressure in appropriate patients)
- **Aspiration** of haematemesis or coffee-ground vomit may cause aspiration pneumonia or pneumonitis - risk is increased in patients with reduced levels of consciousness
- **Complications of endoscopy** e.g. perforation
- **Death** occurs in 10% of patients admitted with an UGIB; mortality is especially high in those who rebleed and require salvage surgery

# NICE Guidelines

[NICE - Acute upper gastrointestinal bleeding in over 16s](https://www.nice.org.uk/guidance/cg141/)

# References
 
[British Society of Gastroenterology - Acute upper GI bleed care bundle](https://www.bsg.org.uk/clinical-resource/bsge-acute-upper-gi-bleed-care-bundle)

[RCEM Learning - Upper Gastrointestinal Haemorrhage](https://www.rcemlearning.co.uk/reference/upper-gastrointestinal-haemorrhage/)

[Patient UK - Upper Gastrointestinal Bleeding](https://patient.info/doctor/upper-gastrointestinal-bleeding-includes-rockall-score)
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A 23-year-old man presents to the emergency department complaining of vomiting blood. He started vomiting last night at a house party, followed by forceful retching a few hours later. Physical examination shows no abnormalities, and he is haemodynamically stable.

What is the most likely diagnosis?
a