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
  • Responsible for around 33%-50% of upper GI bleeding
  • Peptic ulcer disease is most commonly due to H.pylori or nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Upper GI bleeding is the most common complication of peptic ulcer disease and may be the initial presentation.
• Esophageal varices
  • Responsible for around 14% of upper GI bleeding
  • These dilated veins within the esophagus are usually secondary to portal hypertension from cirrhosis.
  • Massive variceal hemorrhage is responsible for acute life-threatening upper GI bleeding which is an medical emergency .
• Mallory-Weiss syndrome :
  • Responsible for around 5% of upper GI bleeding
  • A longitudinal mucosal laceration in the distal esophagus and/or proximal stomach that usually results from forceful retching

Less common causes

• Neoplasms
  • gastric cancer
  • esophageal tumors
• Esophagitis (complications due to erosive or necrotizing infectious esophagitis )
• Gastric erosions/gastropathy
  • 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
  • Dilated aberrant submucosal vessels that erode the overlying epithelium in the absence of an ulcer
• Gastric varices
• 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 history of 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
• Critical illness
  • Nosocomial stress ulcers due the to the use of mechanical ventilation for more than 48 hours, and coagulopathy
  • 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 as Zollinger-Ellison syndrome, mastocytosis, or a retained antrum following partial gastrectomy.

Causes of Acute Upper GI bleeding
Esophagus	Esophagitis Mallory–Weiss tear Esophageal varices Esophageal ulcers Esophageal cancer
Gastric	Gastric ulcer Gastric cancer Gastritis Gastric varices Portal hypertensive gastropathy Gastric antral vascular ectasia Dielafuoy lesions
Duodenal	Duodenal ulcer Vascular malformations, including aorto-enteric Fistulae Bleeding from the bile duct due to Liver biopsy Trauma Arteriovenous malformations Liver tumors

Associated Conditions

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

History

Obtaining the history is the most important aspect of making a diagnosis of upper GI bleed. It provides insight into the cause, precipitating factors and associated comorbid conditions and also helps in determining the severity of the bleed as well as in identifying the potential source of bleed:

• History of any liver disease
• History of NSAID use
• A thorough review of prescription and nonprescription medications
• History of previous aortic repair
• History ulcer disease
• History of binge drinking

Symptoms

• Hematemesis
• Melena
• Hematochezia
• Syncope
• Presyncope
• Dyspepsia
• Epigastric pain
• Heartburn
• Diffuse abdominal pain
• Dysphagia
• Weight loss
• Jaundice