Chapter 042. Gastrointestinal Bleeding (Part 1) pdf

Gastrointestinal Bleeding Part 1 Harrison's Internal Medicine > Chapter 42.. Gastrointestinal Bleeding Gastrointestinal Bleeding: Introduction Bleeding from the gastrointestinal GI tr

Chapter 042 Gastrointestinal

Bleeding (Part 1)

Harrison's Internal Medicine > Chapter 42 Gastrointestinal Bleeding

Gastrointestinal Bleeding: Introduction

Bleeding from the gastrointestinal (GI) tract may present in five ways

Hematemesis is vomitus of red blood or "coffee-grounds" material Melena is

black, tarry, foul-smelling stool Hematochezia is the passage of bright red or maroon blood from the rectum Occult GI bleeding (GIB) may be identified in the

absence of overt bleeding by a fecal occult blood test or the presence of iron

deficiency Finally, patients may present only with symptoms of blood loss or

anemia such as lightheadedness, syncope, angina, or dyspnea

Sources of Gastrointestinal Bleeding

UPPER GASTROINTESTINAL SOURCES OF BLEEDING

(Table 42-1) The annual incidence of hospital admissions for upper GIB (UGIB) in the United States and Europe is ~0.1%, with a mortality rate of ~5– 10% Patients rarely die from exsanguination; rather, they die due to decompensation from other underlying illnesses The mortality rate for patients

<60 years in the absence of major concurrent illness is <1% Independent predictors of rebleeding and death in patients hospitalized with UGIB include increasing age, comorbidities, and hemodynamic compromise (tachycardia or hypotension)

Table 42-1 Sources of Bleeding in Patients Hospitalized for Upper GI Bleeding in Years 2000–2002

Sources of Bleeding Proportion of Patients, %

Ulcers 31–59

Varices 7–20

Mallory-Weiss tears 4–8

Gastroduodenal erosions 2–7

Erosive esophagitis 1–13

Neoplasm 2–7

Vascular ectasias 0–6

No source identified 8–14

Source:

Data from M Van Leerdam et al: Am J Gastroenterol 98:1494, 2003; DM Jensen et al: Gastrointest Endosc 57:AB147, 2003; KC Thomopoulos et al: Eur J Gastroenterol Hepatol 16:177, 2004; F Di Fiore et al: Eur J Gastroenterol Hepatol 17:641, 2005

Peptic ulcers are the most common cause of UGIB, accounting for up to

~50% of cases; an increasing proportion is due to nonsteroidal anti-inflammatory

drugs (NSAIDs), with the prevalence of Helicobacter pylori decreasing

Mallory-Weiss tears account for ~5–10 or 15% of cases

The proportion of patients bleeding from varices varies widely from ~5 to 30%, depending on the population Hemorrhagic or erosive gastropathy (e.g., due

to NSAIDs or alcohol) and erosive esophagitis often cause mild UGIB, but major bleeding is rare