 Welcome to emergency medicine video. In this segment we will discuss the approach to GI bleed. In part 1 of GI bleed, we will discuss the causes and presentations of upper GI bleed. In patients with a potential GI bleed, we usually divide it up into upper and lower GI bleed. The dividing line is the ligament of trites, which extends from the small intestine between the duodenum and the jejunum. Any bleeding that is proximal to that ligament is classified as an upper GI bleed. Any bleeding distal is lower. In this segment, we will focus on the causes and presentation of upper GI bleed. We will discuss each cause and how they might present. Upper GI bleed can present in 4 different ways. Human temesis or blood in the vomit. And if the blood has been sitting in the stomach for a bit of time, when it comes out it will look like coffee ground. Of course blood in the GI tract can come out from the other end as well. It can present as malena if the blood has been digested by the GI tract. Malena is tari black stool. The last way an upper GI bleed can present is bright red blood perectum. If the bleeding is brisk, there has been no time for it to be digested by the GI tract. It will remain bright red. To look at the causes of upper GI bleed, we will look at it anatomically. It includes bleeding from proximal to the esophagus, bleeding from the esophagus, bleeding from the stomach, and bleeding from the duodenum. Let us look at how each of them might present. First, proximal to the esophagus. If any blood proximal to the esophagus is being swallowed, then it will present as an upper GI bleed. The most often seen swallowed blood will be from epistaxis. Therefore on presentation you would want to ask the patient about any history of bleeding. You would also want to look for any obvious bleeding from the source. Swallowed blood can present as coffee ground emesis or malena. Let's move on to the esophagus. There are a few causes of bleeding from the esophagus. They include inflammation, tears, or varices. Esophagitis or inflammation of the esophagus often present with symptoms associated with gastroesophageal reflux. Patient might present with retro sternal chest pain that are worse than lying down, and better when they sit up. The pain is usually worse after a big meal as well. In terms of presentation, it tends to be small volume. It can be hematemesis, coffee ground emesis, or malena. It can also be from a malaria-wise tear. Malvary-wise tear occurs after repeated episodes of vomiting. During the repeated episodes of vomiting a small tear can happen along the esophagus. As a result, the vomit can be streaked with blood. Again, as with esophagitis, blood from malaria-wise tear tend to be in small quantity. The most dangerous cause of bleeding from the esophagus are esophageal varices. They are associated with cirrhosis and portal hypertension. On history, you will want to try to elicit any history associated with liver injury from infection, alcohol, or medication use. Sometimes the patient might be able to tell you that they had a history of esophageal varices and might have had procedures done to them. Esophageal varices bleed heavily and continuously. As a result, you might see large amount of hematemesis, malena, and in cases where there is lots of bleeding that's brisk, even bright red blood perectum. Patients with bleeding esophageal varices tend to be very sick patients. Going further distally, upper GI bleed can be bleeding from the stomach or the duodenum. First, inflammation such as gastritis or deudonitis. These have very similar presentation to patients with esophagitis. They tend to have good symptoms. In terms of presentation, it is very similar to patients with esophagitis. It can present as bleeding through hematemesis, coffee ground emesis, or malena. In all circumstances, blood from gastritis or deudonitis tend to be in small amount as well. The most important cause of bleeding from the stomach and the duodenum is from peptic ulcer disease. Risk factor for peptic ulcer disease include smoking, use of alcohol, and non-steroidal anti-inflammatory. Patient can also present with history of epigastric pain after eating. Patients with peptic ulcer disease can have brisk bleed and they can present with both malena and bright red blood perectum. Varices can also be found in the stomach very occasionally. They're also due to cirrhosis and portal hypertension. They're similar to esophageal varices that they can bleed really quickly as well. We're now going to look at some general causes of bleeding in the upper GI tract. It can be from a vascular disorder or from a bleeding disorder that's either congenital or from drugs such as warfarin. The most often seen vascular cause of an upper GI bleed is known as angiotysplasia. It can happen anywhere in the GI tract. In angiotysplasia, the normally strong wall of the blood vessel has become thin and friable. Therefore, it starts to bleed. If there is an angiotysplastic lesion of one of the small blood vessels in the stomach, it has a specific name called the doule foie lesion. Depending on where the lesion is, angiotysplastic lesion can present as hematemesis, coffee ground emesis, malena or bright red blood perectum. Going further down is a rare but disastrous cause called aorta enteric fistula. It is caused by a previous surgical graft in the aorta that has eroded into the GI tract. The blood now goes from the aorta into the GI tract. As you can imagine, the bleeding would be very brisk. On history, you want to elicit a history of repair of the aorta. The last cause are bleeding disorders that leads to GI bleeding. And they can be congenital or acquired. For congenital bleeding disorder, patients tend to have bleeding in other places on top of GI as well. They can bleed from their gums, internally into their joints, or have hematuria when they urinate. They might also have a family history with bleeding disorder as well. For acquired bleeding disorders, it's often due to drugs. The patient can present with the same kind of bleeding from their gums into their joint or hematuria. The difference is that you should be able to find an offending drug. In summary, we talk about the causes and presentations of upper GI bleed. Remember that upper GI bleed can present as hematemesis, coffee ground emesis, malena or bright red blood perectum. The different causes of upper GI bleed can be classified by anatomical from proximal to distal causes, and also be caused by vascular lesions or drug-induced bleeding disorders. In part two, we'll talk about the causes and presentations of lower GI bleed. We hope you have found this useful. Thank you for watching.