Bleeding that occurs in the esophagus or stomach at the top of the gastrointestinal tract, is referred to as upper gastrointestinal bleeding (UGIB). 

Given the nature of the medical emergency, immediate diagnosis and care are needed. Stomach lining inflammation can result in erosion or ulcers, which can bleed. 

Peptic ulcers are sores that appear on the stomach or duodenum’s lining. They are frequently caused by Helicobacter pylori infection and long-term use of nonsteroidal anti-inflammatory medicines, or binge drinking higher amounts of alcohol. 

Esophageal varices are enlarged veins in the esophagus that can burst and cause serious bleeding. They are typically brought on by liver cirrhosis. 

While incidence and prevalence rates differ globally in such situation research suggests that industrialized countries have higher rates than developing ones. 

As people age, the incidence of UGIB rises, with elderly adults having the greatest rates. This can be partly attributed to the greater usage of anticoagulant and antiplatelet drugs in older populations, as well as the higher prevalence of risk factors such peptic ulcer disease. 

Various factors can cause damage to the mucosal lining of the upper gastrointestinal system, which includes the duodenum, stomach, and esophagus. 

Esophageal vein dilation is frequently brought on by portal hypertension brought on by liver cirrhosis. 

Mucosal superficial erosions that might bleed and are frequently linked to NSAID usage or gastritis. 

The formation of peptic ulcers can also be attributed to stress, alcohol consumption, smoking, and specific drugs. Throat inflammation frequently occurs by viruses, chemical irritants, or GERD.  

Lower esophageal dilated veins are commonly linked to liver cirrhosis and portal hypertension. Tears in the lower esophageal mucous membrane, typically brought on by intense vomiting or retching. 

Complications and mortality in UGIB are linked to advanced age. Comorbidities in elderly adults might make treatment more difficult and raise the possibility of negative results.  

The prognosis of UGIB might be affected by the existence of underlying medical disorders such as malignancies and liver cirrhosis. Comorbidities may limit treatment options and raise the risk of consequences. 

Hypotension, tachycardia, and orthostatic shifts are signs of hemodynamic instability, which is associated with a high risk of hemorrhage. 

Age Group:  

UGIB is more common in older adults, particularly those over the age of 60 or 65. While UGIB is less common in younger adults, it can still occur, particularly in individuals with specific risk factors. 

Associated Comorbidity or Activity:   

Liver cirrhosis is associated with portal hypertension, which can lead to the development of esophageal varices and gastric varices. Rupture of these varices can cause severe UGIB. 

Chronic GERD can lead to erosive esophagitis, increasing the risk of UGIB. Severe cases may develop Barrett’s esophagus, a precancerous condition, which can further elevate the risk of bleeding and malignancy. 

CKD can lead to platelet dysfunction and impaired hemostasis, increasing the risk of bleeding complications in UGIB patients.  

Acuity of Presentation:  

Acute UGIB typically presents with sudden and severe symptoms, often requiring urgent medical attention. 

Melena is another common symptom and suggests bleeding from the upper gastrointestinal tract, where blood is partially digested by gastric acid. 

Hematochezia may also occur if bleeding is rapid and originates from the upper gastrointestinal tract. Subacute UGIB refers to bleeding that occurs over a longer period, often days to weeks, but still requires medical attention. 

Patients may present with symptoms such as intermittent melena, hematemesis, fatigue, weakness, or signs of anemia. 

• General Appearance: Evaluate the patient’s overall appearance, including level of consciousness, alertness, and signs of distress. 
• Skin Examination: Check for signs of peripheral vasoconstriction, such as cool, clammy skin, which may occur in response to hypovolemia. 

Look for signs of bruising or petechiae, which may indicate coagulopathy. 

• Abdominal Examination: Assess for abdominal tenderness, guarding, or rebound tenderness, which may indicate peritonitis or visceral perforation. 

• Initial Assessment and Stabilization: Rapid evaluation of vital signs, airway, breathing, and circulation. Administration of supplemental oxygen to maintain adequate oxygenation. Initiation of crystalloid fluid resuscitation to restore intravascular volume and maintain hemodynamic stability. Consideration of blood transfusion based on the severity of bleeding and hemoglobin levels. 
• Diagnostic Evaluation: Complete blood count (CBC), coagulation profile, comprehensive metabolic panel (CMP), liver function tests (LFTs), and blood typing and crossmatching 
• Imaging studies: Abdominal ultrasound, computed tomography (CT) scan, or angiography may be indicated in certain cases to localize the bleeding source or evaluate for vascular abnormalities. 
• Endoscopic Evaluation: Urgent esophagogastroduodenoscopy (EGD) within 24 hours of presentation to localize the bleeding source, assess the severity of bleeding, and perform therapeutic interventions. 

Gastroenterology

• Emergency Department Triage: Implementation of triage protocols to expedite evaluation and prioritize patients with UGIB based on the severity of bleeding, hemodynamic stability, and comorbidities. 
• Diagnostic Capabilities: Access to point-of-care testing, including rapid hemoglobin measurement, coagulation studies, and blood gas analysis, to facilitate timely assessment of bleeding severity and guide resuscitation efforts. 
• Endoscopy Suite: Dedicated endoscopy suite equipped with state-of-the-art endoscopic instrumentation, video endoscopy systems, and hemostatic devices for performing urgent esophagogastroduodenoscopy (EGD) in patients with UGIB. 
• Surgical Intervention: Coordination with surgical services for rapid evaluation and consultation in patients with refractory bleeding, hemodynamic instability. 

Emergency Medicine

Gastroenterology

• Omeprazole: It inhibits the proton pump in the gastric parietal cells, leading to a profound and long-lasting reduction in gastric acid secretion.  Stabilize blood clots and prevent erosion of ulcers or lesions, thereby reducing the risk of rebleeding. 

• Pantoprazole: It creates an environment conducive to mucosal repair by reducing gastric acidity. This promotes the healing of ulcers and erosions in the upper gastrointestinal tract, including those responsible for UGIB. Promote the formation of stable hemostatic plugs at the bleeding site, facilitating the cessation of bleeding. 

Emergency Medicine

Gastroenterology

• Clarithromycin: It may have anti-inflammatory effects that contribute to the healing of peptic ulcers and resolution of mucosal inflammation. By reducing mucosal inflammation and promoting ulcer healing, clarithromycin may help to prevent recurrent bleeding in patients with peptic ulcer disease. 

• Injection Therapy: Epinephrine injection is commonly used to achieve hemostasis by causing vasoconstriction and tamponading bleeding vessels. 
• Thermal Therapy: Various modalities, such as thermal coagulation or argon plasma coagulation, can be used to cauterize bleeding vessels and promote hemostasis. 
• Mechanical Therapy: Hemostatic clips or band ligation may be deployed to mechanically close off bleeding vessels or ulcers. 
• Hemostatic Sprays: Topical hemostatic agents, such as hemostatic sprays or powders, can be applied to actively bleeding lesions to promote clot formation and hemostasis. 

Critical Care/Intensive Care

Gastroenterology

• Initial Assessment and Resuscitation: Prompt recognition of UGIB through clinical assessment, including history-taking and physical examination. 
• Diagnostic Evaluation: Rapid diagnostic workup to determine the cause and severity of UGIB, including laboratory tests, imaging studies e.g., abdominal ultrasound, computed tomography, and endoscopic evaluation. 

• Prevention of Rebleeding and Complications: Maintenance therapy with proton pump inhibitors after endoscopic hemostasis to reduce the risk of rebleeding and promote ulcer healing. Surveillance endoscopy for high-risk patients to assess for rebleeding and perform additional interventions if necessary.