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Tuesday, 26 November 2013

Upper gastrointestinal bleeding – The Causes

The prevalence of upper gastrointestinal (GI) diseases is increasing in subjects aged 65 years and over. Pathophysiological changes in esophageal functions that occur with aging may, at least in part, be responsible for the high prevalence of
1. Gastro-esophageal reflux disease (GERD) in old age.
2. The incidence of gastric and duodenal ulcers and their bleeding complications is increasing in old-aged populations worldwide.
3.  H. pylori infection in elderly patients with H. pylori-associated peptic ulcer disease and severe chronic gastritis
4.  Almost 40% of GU and 25% of DU in the elderly patients are associated with the use of NSAID(1) and/or aspirin(2).(a)
IV. Upper gastrointestinal bleeding 
Upper gastrointestinal bleeding (UGIB) is defined as hemorrhaging derived from a source proximal to the ligament of Treitz. It is life threatening and considered as medical emergency, which is followed by high mortality rate, ranging from 6 to 15% in spite of modern diagnostic methods and treatment.
A. The Causes
1.1. Esophageal causes of Upper gastrointestinal bleeding
Espophagus or gullet, an organ in vertebrates, is the tube that lead foods from the pharynx to the stomach.
1. Esophageal varices
In the study to investigate the effects of splenectomy and ligature of the left gastric vein on risk factors for bleeding of esophagogastric varices in patients with schistosomiasis mansoni, hepatosplenic form, with a history of upper gastrointestinal bleeding, showed that the variceal pressure has fallen from 22.3+/-2.6 mmHg before surgery to 16.0+/-3.0 mmHg in the immediate postoperative period (p<0.001), reaching 13.3+/- 2.6 mmHg in the sixth month of follow-up. A significant reduction of the frequency of the parameters associated with a greater risk of hemorrhage was observed between the preoperative period and six-month follow-up, when the proportion of large esophageal varices (p<0.05), varices extending to the upper esophagus (p<0.05), bluish varices (p<0.01), varices with red signs (p<0.01) and gastropathy (p<0.05) decreased(1)

2. Esophagitis

there is a report of a case of recurrent, severe upper gastrointestinal bleeding due to hemorrhagic candidal esophagitis in a man with renal failure is described. Dysphagia, odynophagia, and retrosternal chest discomfort were all absent. Oral thrush was present only at the outset. Standard therapy for massive bleeding with blood products alone was not successful. Intravenous amphotericin eventually resulted in resolution, according to the study by University of Manitoba, Canada(2).
3. Esophageal cancer
Esophageal cancer is not very uncommon and caused by malignant of the esophagus due to abnormal cell growth as a result of the DNA alternation of the cells that line the upper part of the esophagus or glandular cells that are present at the lower part of the esophagus that connected with the stomach.
The esophageal cancer tend to spread if it left untreated and starts from the lining of esophagus, then later penetrate in the the wall of the esophagus and spread to the lumph node around the bottom of the esophagus, stomach and the chest, then to the distant parts of the body. 
4. Esophageal ulcers
there is a report of five cases in the upper GI tract due to insufflating large amounts of air through the endoscopes. All 5 patients needed an emergency upper endoscopy for acute presumed upper GI bleeding. In two cases both esophageal variceal bleeding and ulcer bleeding were detected; the fifth case presented with a bleeding due to gastric cancer(3).
5. Other causes
Other causes of UGI bleeding include Dieulafoy’s lesion, Mallory-Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids(4). 

1.2. Gastric causes of Upper gastrointestinal bleedinga
1. Gastric ulcer 
There is a report iIn 16 patients (mean age, 59.4 years) with acute bleeding ulcers (13 gastric ulcers, 2 duodenal ulcers, 1 malignant ulcer), a metallic clip was placed via gastroscopy and this had been preceded by routine endoscopic treatment, according to the study of Chonbuk National University Medical School(5).
2. Gastric cancer 
Bleeding from the upper gastrointestinal system may be caused by gastrointestinal stromal tumors of the stomach, which are mainly characterized by occult bleeding, while profuse bleeding rarely occurs accompanied by hemorrhagic shock. Gastrointestinal stromal tumors of stomach are the most common mesenchimal tumors of the gastrointestinal tract(1). For more information of Stomach Cancer/Gastric Cancer, please visit http://medicaladvisorjournals.blogspot.ca/2011/06/cancers-from-b-to-t-most-common-types_30.html
3. Gastritis 
In a material of 4560 panendoscopic investigations carried out in an endoscopy laboratory haemorrhages from the upper gastrointestinal tract were found in 201 cases. In 49 cases the cause of blood loss was acute haemorrhagic gastritis. Among them males accounted for 41% (mean age 35.6 years) and females for 59% (mean age 41.8 years)(6).
4. Gastric varices 
Although most portal hypertensive bleeds result from the ruptured distal esophageal varices, bleeding from other sources such gastric varices, portal hypertensive gastropathy, and ectopic varices can lead to clinically significant bleeding. Variceal bleeding typically presents as massive gastrointestinal (GI) bleeding with hematemesis, melena or hematochezia(7).
5. Gastric antral vascular ectasia 
Gastric antral vascular ectasia (GAVE) syndrome, also known as watermelon stomach is a significant cause of acute or chronic gastrointestinal blood loss in the elderly. is characterized endoscopically by “watermelon stripes.” Without cirrhosis, patients are 71% female, average age 73, presenting with occult blood loss leading to transfusion-dependent chronic iron-deficiency anemia, severe acute upper gastrointestinal bleeding, and nondescript abdominal pain(8).
6. Dieulafoy’s lesions
Dieulafoy’s lesions are considered uncommon causes of gastrointestinal bleeding and occur from pinpoint non-ulcerated arterial lesions(9).
7. Etc.
1.3. Duodenal causes of Upper gastrointestinal bleeding
The duodenum represents second place in frequency for the presence of diverticula in the digestive tract after the colon. Duodenal diverticulum as a cause of hemorrhage of the upper gastrointestinal (GI) tract has been described as an infrequent complication, although it must be considered in patients with digestive hemorrhage without evident cause at the esophagogastric level(10).
1.4. Etc.
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Sources
(1a) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1065003/table/T1/ 
(1) http://www.ncbi.nlm.nih.gov/pubmed/22569978
(2) http://www.ncbi.nlm.nih.gov/pubmed/8202782
(3) http://www.ncbi.nlm.nih.gov/pubmed/22649332
(4) http://www.ncbi.nlm.nih.gov/pubmed/22661272
(5) http://www.ncbi.nlm.nih.gov/pubmed/21852908
(6) http://www.ncbi.nlm.nih.gov/pubmed/2623868
(7) http://www.ncbi.nlm.nih.gov/pubmed/22514572
(8) http://www.ncbi.nlm.nih.gov/pubmed/20740102
(9) http://www.ncbi.nlm.nih.gov/pubmed/20514835
(10) http://www.ncbi.nlm.nih.gov/pubmed/18492423