Sandbox:Aditya

HAS-BLED score

Components	Points
Hypertension	1
Abnormal renal/liver functions Dialysis, Kidney transplantation, Creatinine >2.6 mg/dl Cirrhosis, total bilirubanc>2X, AST/ALT >3e	1
Stroke	1
Bleeding history	1
Liable INR	1
Elderly( >65 years)	1
Drugs	1
INTERPRETATION OF HAS-BLED score
1	3%
2	4%
3	5%
4	8%
5	9%

Causes

Common causes

• Peptic ulcer disease (33%-50%): Peptic ulcer disease is most commonly due toH pylorior nonsteroidal anti-inflammatory drugs (NSAIDs). Bleeding is the most common complication of this disease, and may be the initial presentation.
• Esophageal varices (14%): These dilated veins within the esophagus are usually secondary to portal hypertension from cirrhosis. Massive variceal hemorrhage is a life-threatening medical emergency.
• Mallory-Weiss syndrome (5%): a longitudinal mucosal laceration in the distal esophagus and/or proximal stomach that usually results from forceful retching

Less common causes

• Neoplasms, most commonly gastric cancer or esophageal tumors (4%)
• Esophagitis (eg, complications due to erosive or necrotizing infectious esophagitis )
• Gastric erosions/gastropathy (4%), such as from acute erosive gastritis caused by drugs, radiation, infection, or direct trauma. Reactive gastropathy may be due to bile reflux, particularly after partial gastrectomy
• Portal hypertensive gastropathy, which results in increased friability of gastric mucosa in patients with cirrhosis
• Dieulafoy lesions (1%): dilated aberrant submucosal vessels that erode the overlying epithelium in the absence of an ulcer
• Gastric varices (as a result of splenic vein thrombosis)
• Gastric antral vascular ectasia: dilated gastric vessels of unknown etiology that cause chronic UGIB and iron-deficiency anemia

Rare causes

• Hemobilia, or bleeding from the hepatobiliary tract, most commonly secondary to liver or biliary tract injury, from trauma or following procedures or surgery. Classically accompanied by upper abdominal pain and jaundice. Diagnosed by endoscopic retrograde cholangiopancreatography (ERCP) and treated with arteriography
• Aortoenteric fistulas, usually involving the lower duodenum, are secondary to aortic aneurysms or prosthetic vascular grafts; syphilis and tuberculosis are common causes in developing countries. Presents with frank UGIB along with a pulsatile mass and abdominal pain radiating to the back. Diagnosed by endoscopy. Very high morality rate despite surgical repair
• Crohn disease involving the upper gastrointestinal tract
• Metastatic malignancy involving the upper gastrointestinal tract, such as melanoma or renal cell carcinoma
• Hemosuccus pancreaticus
  • Pancreatic inflammation or cancer may result in bleeding into the pancreatic duct, which connects to the duodenum

Risk factors

• Advancing age
• Previous gastrointestinal bleed
• Chronic kidney disease
• Underlying cardiovascular disease
• Cirrhosis and portal hypertension
• Presence of H.pylori
• NSAID or aspirin use in patients with a history of ulcer disease; those on dual antiplatelet therapy; those on anticoagulant therapy; or those with two or more of the following risk factors
  • age 60 years or older
  • glucocorticoid use,
  • dyspepsia
  • gastroesophageal reflux disease
• Use of other antiplatelet agents
• Critical illness
  • The two major risk factors for UGIB due to nosocomial stress ulcers are use of mechanical ventilation for more than 48 hours, and coagulopathy (platelet count fewer than 50,000, international normalized ratio [INR] greater than 1.5, or activated partial thromboplastin time [aPTT] more than two times the control value).
  • Other risk factors for nosocomial stress ulcerations in critically ill patients include a history of gastrointestinal ulceration or bleeding within the past year; or two or more of the following risk factors: presence of sepsis, ICU admission lasting longer than 1 week, occult gastrointestinal bleeding lasting 6 days or longer, and administration of more than 250 mg of hydrocortisone or equivalent glucocorticoid therapy
• Rare conditions associated with gastric acid hypersecretion, such asZollinger-Ellison syndrome, mastocytosis, or a retained antrum following partial gastrectomy

Associated Conditions

• Heyde syndrome, aortic valve stenosis with associated gastrointestinal bleeding thought to be due to acquired reduction of von Willebrand factor.