Upper Gastrointestinal Bleeding

Introduction

Upper gastrointestinal (GI) bleeding is a common and potentially life-threatening condition that Canadian physicians must be prepared to diagnose and manage. This comprehensive guide is designed to help you prepare for the MCCQE1 exam, focusing on the key aspects of upper GI bleeding within the Canadian healthcare context.

Epidemiology in Canada

Understanding the prevalence and impact of upper GI bleeding in Canada is crucial for MCCQE1 preparation:

• Annual incidence: Approximately 100 cases per 100,000 adults
• Mortality rate: 5-10% (lower than global average due to Canada's universal healthcare system)
• Most common in: Elderly population (>65 years)
• Gender distribution: More common in males (1.5-2:1 ratio)

Etiology

Understanding the causes of upper GI bleeding is essential for diagnosis and management. Here are the most common etiologies, organized by frequency in the Canadian population:

1. Peptic ulcer disease (40-50%)
2. Esophageal varices (10-20%)
3. Mallory-Weiss tears (5-15%)
4. Erosive esophagitis (5-10%)
5. Gastric/duodenal erosions (5-10%)
6. Neoplasms (1-5%)

Clinical Presentation

Recognizing the signs and symptoms of upper GI bleeding is crucial for prompt diagnosis and management. Key presentations include:

• Hematemesis (vomiting of blood or coffee-ground material)
• Melena (black, tarry stools)
• Hematochezia (bright red blood per rectum, in severe cases)
• Syncope or presyncope
• Weakness, fatigue, or shortness of breath (due to anemia)
• Abdominal pain (in some cases)

Diagnostic Approach

A systematic approach to diagnosis is essential for MCCQE1 success. Follow these steps:

Management

Management of upper GI bleeding in Canada follows a stepwise approach:

1. Resuscitation

   • Establish large-bore IV access
   • Fluid resuscitation with crystalloids
   • Blood transfusion if hemoglobin <70 g/L (or <80 g/L in patients with cardiovascular disease)

2. Medical Management

   • Proton pump inhibitors (PPI): High-dose IV infusion
   • Octreotide: For suspected variceal bleeding
   • Antibiotics: For patients with cirrhosis and suspected variceal bleeding

3. Endoscopic Management

   • Timing: Within 24 hours for most patients, earlier for high-risk cases
   • Techniques: Injection therapy, thermal coagulation, mechanical clips, or band ligation

4. Interventional Radiology

   • Angiographic embolization for refractory bleeding

5. Surgical Management

   • Reserved for cases refractory to endoscopic and radiologic interventions

Risk Stratification

The Glasgow-Blatchford Score (GBS) is commonly used in Canada for risk stratification:

A score of 0-1 indicates low risk and potential for outpatient management.

Prevention

Preventive strategies are crucial in reducing the incidence of upper GI bleeding:

• H. pylori eradication: Test and treat strategy in high-risk patients
• PPI prophylaxis: For patients on long-term NSAID therapy
• Lifestyle modifications: Smoking cessation, alcohol reduction
• Anticoagulation management: Careful monitoring and appropriate indications

Canadian Guidelines

The Canadian Association of Gastroenterology (CAG) provides specific guidelines for managing upper GI bleeding:

1. Use of pre-endoscopic erythromycin: Recommended to improve visualization during endoscopy
2. Timing of endoscopy: Within 24 hours for most patients
3. Second-look endoscopy: Not routinely recommended
4. PPI therapy: High-dose IV followed by oral therapy
5. H. pylori testing: Recommended for all patients with peptic ulcer bleeding

Key Points to Remember for MCCQE1

1. Upper GI bleeding is a common and potentially life-threatening condition in Canada
2. Peptic ulcer disease is the most common cause, followed by esophageal varices
3. The Glasgow-Blatchford Score is used for risk stratification
4. Early endoscopy (within 24 hours) is recommended for most patients
5. Canadian guidelines emphasize H. pylori testing and eradication in peptic ulcer bleeding
6. PPI therapy is a cornerstone of management in non-variceal bleeding
7. Octreotide and antibiotics are crucial in managing variceal bleeding in cirrhotic patients
8. Prevention strategies include H. pylori eradication and appropriate use of PPI prophylaxis

Sample Question

A 65-year-old man presents to the emergency department with a 2-day history of passing black, tarry stools. He has a history of osteoarthritis and has been taking ibuprofen regularly for pain relief. On examination, his heart rate is 110 bpm, and his blood pressure is 100/60 mmHg. His hemoglobin is 85 g/L. Which one of the following is the most appropriate next step in management?

• A. Immediate blood transfusion
• B. CT angiography
• C. Admission for observation
• D. Outpatient follow-up
• E. Urgent upper endoscopy

Explanation

The correct answer is:

• E. Urgent upper endoscopy

This patient presents with signs of upper GI bleeding (melena) and has risk factors (NSAID use, tachycardia, hypotension, and low hemoglobin). According to Canadian guidelines, urgent upper endoscopy within 24 hours is the most appropriate next step. This allows for both diagnosis and potential therapeutic intervention.

Option A (immediate blood transfusion) is not correct as the patient's hemoglobin is above the transfusion threshold of 70 g/L. Option B (CT angiography) is not the first-line investigation for upper GI bleeding. Option C (admission for observation) delays definitive diagnosis and treatment. Option D (outpatient follow-up) is inappropriate given the patient's presentation and vital signs.

References

1. Barkun, A. N., Bardou, M., Kuipers, E. J., Sung, J., Hunt, R. H., Martel, M., & Sinclair, P. (2010). International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Annals of internal medicine, 152(2), 101-113.

2. Blatchford, O., Murray, W. R., & Blatchford, M. (2000). A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. The Lancet, 356(9238), 1318-1321.

3. Canadian Association of Gastroenterology. (2019). Clinical Practice Guidelines for the Management of Nonvariceal Upper Gastrointestinal Bleeding. Journal of the Canadian Association of Gastroenterology, 2(1), 1-21.

4. Gralnek, I. M., Dumonceau, J. M., Kuipers, E. J., Lanas, A., Sanders, D. S., Kurien, M., ... & Hassan, C. (2015). Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy, 47(10), a1-a46.

5. Kaplan, G. G., Gregson, D. B., & Laupland, K. B. (2004). Population-based study of the epidemiology of and the risk factors for pyogenic liver abscess. Clinical Gastroenterology and Hepatology, 2(11), 1032-1038.

6. Laine, L., & Jensen, D. M. (2012). Management of patients with ulcer bleeding. American Journal of Gastroenterology, 107(3), 345-360.

7. Rotondano, G. (2014). Epidemiology and diagnosis of acute nonvariceal upper gastrointestinal bleeding. Gastroenterology Clinics, 43(4), 643-663.