Hepatic Failure/GI/Endocrine Emergencies
Mortality at 28 days after hospital admission for non-variceal hemorrhage is about 13%, whereas
mortality after variceal hemorrhage is about 20%. Mortality rates after both UGIB classifications seem
to be decreasing with advances in care.
Nonvariceal hemorrhage
Gastric and/or duodenal ulcer
Most common cause of severe cases of UGIB, accounting for 47% of all UGIB episodes
ii.
Bleeding is more common in the setting of anticoagulant use and is typically self-limited.
iii.
Most commonly caused by an H. pylori infection, but may also be secondary to NSAIDs,
hyperacidity (e.g., in Zollinger-Ellison syndrome), or stress-related mucosal disease (stress-
related mucosal damage is discussed in detail in the Supportive and Preventive Medicine
chapter)
Esophagitis
Noted in around 13% of patients with UGIB
ii.
Risk factors include history of gastroesophageal reflux disease, medication use (e.g., NSAIDs,
oral bisphosphonates, tetracycline), and infection (e.g., Candida, herpes simplex virus).
iii.
Commonly presents with hematemesis and less commonly associated with melena
iv.
Lower rebleeding and mortality rate than other sources of UGIB
Gastroduodenal erosions (erosive gastritis/duodenitis): Defects of the gastric/duodenal mucosal
layer that lead to inflammation without ulcer formation
Causes are similar to those for gastric/duodenal ulcers. Additional risk factors include excessive
alcohol consumption, radiation injury, bariatric surgery, and chronic bile reflux.
ii.
Bleeding is more common in the setting of anticoagulant use and is typically self-limited.
iii.
May progress to ulcer formation
| d. | Mallory-Weiss tear: A longitudinal mucosal laceration in the distal esophagus and proximal |
|---|
stomach (an intramural dissection)
A sudden increase in intra-abdominal pressure leads to forceful distention of the
gastroesophageal junction and a resultant mucosal tear.
ii.
Typically caused by forceful vomiting
Less common causes: Vascular malformation, malignant formations, aortoenteric fistulas, gastric
antral vascular ectasia, and prolapse gastropathy
Relatively few severe cases of UGIB are secondary to variceal hemorrhage (< 5%), but the incidence
is higher in patients with cirrhosis.
Mortality rate is around 20% at 6 weeks.
Portal hypertension caused by the obstruction of venous blood flow through the cirrhotic liver leads
to increased pressure in the portal vein and causes the redirection of blood flow to other areas of
the body.
| d. | Varices may be present in any portion of the GI tract, but they are most common in the esophagus |
|---|
and stomach.
Gastroesophageal varices are present in about 50% of patients with cirrhosis. About 12% of patients
with varices will develop variceal hemorrhage within 1 year of diagnosis, and the recurrence rate
for variceal hemorrhage within 1 year is about 60%.
Most patients (50%) present with both melena and hematemesis; 30% have hematemesis (either red
blood or βcoffee-groundβ emesis) alone, and 20% have melena alone.
represent a swift UGIB (about 1 L of blood is needed in the stomach to cause hematochezia, whereas
only 50β100 mL is needed to cause melena).