Non-variceal Upper Gastrointestinal Bleeding and Its Endoscopic Management

Abstract

Upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality. Clinical symptoms that patients may present with include: hematemesis, coffee-ground emesis, melena, and hematochezia. Clinical signs can range from tachycardia to shock. The anatomical landmark that differentiates upper gastrointestinal (GI) bleeds from lower bleeds is the ligament of Treitz. The first steps of treating a patient who presents with signs of UGIB are resuscitation with appropriate fluids and blood products as necessary. The consideration of endoscopy and the urgency at which it should be performed is also vital during initial resuscitation. Endoscopic therapy should ideally be performed within 24 hours of presentation after initial stabilization with crystalloids and blood products. Intravenous proton pump inhibitors are the mainstay in the initial management of upper GI bleeding from a non-variceal etiology, and they should be administered in the acute setting to decrease the probability of high-risk stigmata seen during endoscopy. Pro-kinetic agents can be given 30 minutes to an hour before endoscopy and may aid in the diagnosis of UGIB. There are 3 broad categories of endoscopic management for UGIB: injection, thermal, and mechanical. Each endoscopic method can be used alone or in combination with others; however, the injection technique with epinephrine should always be used in conjunction with another method to increase the success of achieving hemostasis. In this review article, we will review the steps of triage and initial resuscitation in UGIB, causes of UGIB and their respective management, several endoscopic techniques and their effectiveness, and prognosis with a primary focus limited to non-variceal bleeding.

Figure 1.

Etiologies of upper gastrointestinal bleeding by percentage.

Figure 2.

Various etiologies of upper gastrointestinal bleeding. A. Blood oozing peptic ulcer located in the duodenal bulb covered with an adherent clot. B. Bleeding duodenal Dieulafoy lesion on the greater curvature of the gastric body. C. Mallory–Weiss tear at typical location, on the distal esophagus, at the Z-line on the right side, which corresponds to the lesser curvature of the stomach. D. Severe erosive esophagitis, grade D based on the Los Angeles classification. E. Typical duodenal angiodysplasia. F. Large submucosal gastric tumor with ulcerated center. This is a gastrointestinal stromal tumor.

Figure 3.

Common accessories employed for endoscopic therapy. (A) Injection needle (yellow arrow). (B) Epinephrine-saline mix 1 : 20 000 injected into the bleeding ulcer. (C) Bipolar electrocoagulation using the gold-probe (also see insert). The gold probe also has a needle, facilitating a dual endoscopic therapy. (D) The arrows show the gold probe tip, tightly applied against the visible vessel. This maneuver is essential to induce adequate cauterization and hemostasis. (E) Hemoclip. (F) Large bleeding lesion in the stomach in a patient who underwent surgical enucleation of a leiomyoma. (G) Technique of “zipper-clipping” resulting in adequate hemostasis. (H) Hemoclip placed on a visible vessel with an adherent clot.

Figure 4.

Esophagogastric varices. (A). Bleeding distal esophageal varices. Notice the blood emanating from the “nipple sign.” (B) Grade 4 esophageal varices based on the Paquet classification. (C) The esophageal varices were banded with excellent proximal decompression. (D) Gastric varices extending from the gastroesophageal junction to the fundus, which corresponds to type Gastroesophageal varix (GOV) II based on the Sarin classification. (E) Bleeding gastric varix. (F) Successful hemostasis of bleeding gastric varix using glue (Histoacryl) injection.

Figure 5.

Gastric antral vascular ectasia (GAVE). (A) Honeycomb type with active bleeding. (B) We call this the large fold type. Usually, there are no folds in the antrum. (C) Typical appearance of nodular type GAVE.