Which clinical history findings are characteristic of upper gastrointestinal bleeding (UGIB)?

Updated: Aug 12, 2019
  • Author: Bennie Ray Upchurch, III, MD, FACP, AGAF, FACG, FASGE; Chief Editor: BS Anand, MD  more...
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Answer

The history and physical examination of the patient provide crucial information for the initial evaluation of persons presenting with a gastrointestinal (GI) tract hemorrhage. [5, 10] Important information to obtain includes potential comorbid conditions, medication history, and any prior history of GI bleeding, as well as the severity, timing, duration, and volume of the bleeding. [5]

History findings include weakness, dizziness, syncope associated with hematemesis (coffee ground vomitus), and melena (black stools with a rotten odor).

Occasionally, a brisk upper GI bleeding (UGIB) manifests as hematochezia (red or maroon stools); the redder the stool, the more rapid the transit, which suggests a large upper tract hemorrhage. Laine and Shah found that 15% of patients presenting with hematochezia had an upper GI source of bleeding identified at urgent esophagogastroduodenoscopy. [27]

Patients may have a history of dyspepsia (especially nocturnal symptoms), ulcer disease, early satiety, and nonsteroidal anti-inflammatory drug (NSAID), antiplatelet therapy, or aspirin use. A history of recent aspirin ingestion suggests that the patient may have NSAID gastropathy with an enhanced bleeding diathesis from poor platelet adhesiveness. [10]

Many patients with UGIB who are taking NSAIDs present without dyspepsia but with hematemesis or melena as their first symptom, owing to the analgesic effect of the NSAID. Low-dose aspirin (81 mg) has also been associated with UGIB, with or without the addition of NSAID therapy. Using the lowest effective dose for both short-term and long-term users is recommended. [28]

Patients with a history of ulcers are at an especially increased risk for UGIB when taking steroids, aspirin, dual antiplatelet therapy (DAPT) (eg, addition of clopidogrel to aspirin), or NSAID therapy. These high-risk individuals should receive continuous acid suppression with a proton pump inhibitor (PPI). The patient’s ulcer history is also important because recurrence of ulcer disease is common, especially there has not been successful eradication of an H pylori infection.

Patients may present asymptomatically or in a more subacute phase, with a history of dyspepsia and occult intestinal bleeding manifesting as a positive fecal occult blood test result or as iron deficiency anemia.

A history of chronic alcohol use of more than 50 g/d or chronic viral hepatitis (B or C) increases the risk of variceal hemorrhage, gastric antral vascular ectasia (GAVE), or portal gastropathy. Alcohol also interferes with cyclooxygenase (COX)-1 receptor enzymes which reduce the production of cytoprotective prostaglandin and alters gastric mucosal protection.

The finding of subcutaneous emphysema with a history of vomiting is suggestive of Boerhaave syndrome (esophageal perforation) and requires prompt consideration of surgical therapy.

The presence of postural hypotension indicates more rapid and severe blood loss.

A meta-analysis documented the incidence of acute UGIB symptoms as follows (see Physical Examination) [1] :

  • Hematemesis: 40%-50%
  • Melena: 70%-80%
  • Hematochezia: 15%-20%
  • Either hematochezia or melena: 90%-98%
  • Syncope: 14.4%
  • Presyncope: 43.2%
  • Symptoms 30 days prior to admission: No percentage available
  • Dyspepsia: 18%
  • Epigastric pain: 41%
  • Heartburn: 21%
  • Diffuse abdominal pain: 10%
  • Dysphagia: 5%
  • Weight loss: 12%
  • Jaundice: 5.2%

The importance of the above clinical signs/symptoms in determining the source of GI bleeding is demonstrated in the table below. [1]

Table 1. Probable Source of GI Bleeding Within the Gut (Open Table in a new window)

Clinical Indicator

Probability of Upper GI Source

Probability of Lower GI Source

Hematemesis

Almost certain

Rare

Melena

Probable

Possible

Hematochezia

Possible

Probable

Blood-streaked stool

Rare

Almost certain

Occult blood in stool

Possible

Possible

GI = gastrointestinal.


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