The treatment program for upper gastrointestinal hemorrhage is shown in Fig 1.
Fig. 1 Treatment program for upper gastrointestinal hemorrhage: ICU, intensive care unit; GI, gastrointestinal; MW, Mallory-Weiss; prn, whenever necessary.
Esophageal sources other than varices
Hemorrhage from the esophagus, generally associated with hematemesis, is caused most commonly by mucosal tears at the gastroesophageal junction
(Mallory-Weiss lesions). This disorder is usually precipitated by bouts of retching or vomiting of clear non-bloody gastric contents, indicating that the retching itself may have led to the subsequent bleeding. The syndrome is often preceded by an alcoholic debauch, or following ingestion or administration of nauseant drugs. The diagnosis is often suspected by a history suggesting that the contraction of abdominal and diaphragmatic muscles has led to stretch forces on the esophagogastric mucosa. It is confirmed by endoscopic visualization of the lesions themselves. Bleeding often ceases spontaneously, or can be controlled by endoscopic coagulation of the oozing areas with a bipolar (Bicap) electric probe. Patients with Mallory-Weiss syndrome should be examined for subcutaneous emphysema, which indicates the presence of tears through the esophageal wall into the mediastinum (Boerhaave syndrome) and requires early surgical repair.
Reflux esophagitis is another common cause of esophageal bleeding. This diagnosis is suspected when guaiac-positive stools or small amounts of melena are discovered in a patient experiencing frequent bouts of heartburn, particularly when in a recumbent position. The disorder results from repeated reflux and retention of acid-peptic gastric contents in the esophagus as a result of both reduced resting pressure at the level of the inferior esophageal sphincter and delayed esophageal emptying. While the inflammatory process is usually mild and bleeding is slight, actual mucosal dysplasia (Barrett epithelium) leading to ulcers and strictures may occur in severe chronic cases. In immunocompromised patients in particular, several types of mycoses (especially candidiasis) or viral infections may cause extensive esophagitis and dysphagia, usually with minor bleeding. These disorders are generally responsive to specific chemotherapeutic drugs. Cancer of the esophagus is unlikely to cause major bleeding unless the tumor penetrates into a large submucosal blood vessel. Rarely, a bronchogenic carcinoma may erode into the esophagus and cause heavy bleeding, usually preceded by a period of dysphagia.
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