Upper gastrointestinal bleeding

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Upper gastrointestinal bleeding
Other namesUpper gastrointestinal hemorrhage, gastrorrhagia, upper GI bleed, UGI bleed
DU 2.jpg
Endoscopic image of a posterior wall duodenal ulcer with a clean base, which is a common cause of upper gastrointestinal hemorrhage.
Specialty Gastroenterology
Symptoms Hematemesis (vomiting blood), coffee ground vomiting, melena, hematochezia (maroon-coloured stool) in severe cases

Upper gastrointestinal bleeding is gastrointestinal bleeding (hemorrhage) in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit or in altered form as black stool. Depending on the amount of the blood loss, symptoms may include shock.

Contents

Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and rarer causes such as gastric cancer. The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine the hemoglobin.

Significant upper gastrointestinal bleeding is considered a medical emergency. Fluid replacement, as well as blood transfusion, may be required. Endoscopy is recommended within 24 hours and bleeding can be stopped by various techniques. [1] Proton pump inhibitors are often used. [2] Tranexamic acid may also be useful. [2] Procedures (such as TIPS for variceal bleeding) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.

Upper gastrointestinal bleeding affects around 50 to 150 people per 100,000 a year. It represents over 50% of cases of gastrointestinal bleeding. [2] A 1995 UK study found an estimated mortality risk of 11% in those admitted to hospital for gastrointestinal bleeding. [3]

Signs and symptoms

Persons with upper gastrointestinal bleeding often present with hematemesis, coffee ground vomiting, melena, or hematochezia (maroon-coloured stool) if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage. A person with upper gastrointestinal bleeding may also present with complications of anemia, including chest pain, syncope, fatigue and shortness of breath.[ citation needed ]

The physical examination performed by the physician concentrates on the following things:[ citation needed ]

Laboratory findings include anemia, coagulopathy, and an elevated BUN-to-creatinine ratio.

Causes

Gastric ulcer in antrum of stomach with overlying clot. Pathology was consistent with gastric lymphoma. MALT 4.jpg
Gastric ulcer in antrum of stomach with overlying clot. Pathology was consistent with gastric lymphoma.

A number of medications increase the risk of bleeding including NSAIDs and SSRIs. SSRIs double the rate of upper gastrointestinal bleeding. [4]

There are many causes for upper gastrointestinal hemorrhage. Causes are usually anatomically divided into their location in the upper gastrointestinal tract.[ citation needed ]

People are usually stratified into having either variceal or non-variceal sources of upper gastrointestinal hemorrhage, as the two have different treatment algorithms and prognosis.[ citation needed ]

The causes for upper gastrointestinal hemorrhage include the following:

Diagnosis

Endoscopic image of small gastric ulcer with visible vessel Gastric ulcer 2.jpg
Endoscopic image of small gastric ulcer with visible vessel

Diagnostic testing

The strongest predictors of an upper gastrointestinal bleed are black stool, age <50 years, and blood urea nitrogen/creatinine ratio 30 or more. [8] [9] The diagnosis of upper gastrointestinal bleeding is assumed when hematemesis (vomiting of blood) is observed.[ citation needed ]

A nasogastric aspirate can help determine the location (source) of bleeding and help understand the best initial diagnostic and treatment plan. Nasogastric aspirate has a sensitivity of 42%, specificity 91%, negative predictive value 64%, positive predictive value 92% and overall accuracy of 66% in differentiating upper gastrointestinal bleeding from bleeding distal to the ligament of Treitz. [8] A positive aspirate is more helpful than a negative aspirate (If the aspirate is positive, an upper gastrointestinal bleed is likely; if the aspirate is negative, the source of a gastrointestinal bleed is probably, but not certainly, lower). A smaller study found a sensitivity of 79% and specificity of 55%, somewhat opposite results from Witting. [10] The accuracy of the aspirate is improved by using the Gastroccult test.[ citation needed ]

Determining whether blood is in gastric contents, either vomited or aspirated specimens, may be a challenge when determining the source of the hemorrhage. Slide tests are based on orthotolidine (Hematest reagent tablets and Bili-Labstix) or guaiac (Hemoccult and Gastroccult). There is some evidence that orthotolidine-based tests more sensitive than specific, the Hemoccult test's sensitivity reduced by the acidic environment; and the Gastroccult test be the most accurate. [11] The sensitivity, specificity, positive predictive value, and negative predictive value have been reported as follows: [10]

Determining whether blood is in the gastric aspirate [10]
FindingSensitivitySpecificityPositive predictive value
(prevalence of 39%)		Negative predictive value
(prevalence of 39%)
Gastroccult95%82%77%96%
Physician assessment79%55%53%20%

Holman used simulated gastric specimens and found the Hemoccult test to have significant problems with non-specificity and false-positive results, whereas the Gastroccult test was very accurate. [12] Holman found that by 120 seconds after the developer was applied, the Hemoccult test was positive on all control samples.

A scoring system called the Glasgow-Blatchford bleeding score found 16% of people presenting with upper gastrointestinal bleed had Glasgow-Blatchford score of "0", considered low. Among these people there were no deaths or interventions needed and they were able to be effectively treated in an outpatient setting. [13] [14]

Score is equal to "0" if the following are all present:

  1. Hemoglobin level >12.9 g/dL (men) or >11.9 g/dL (women)
  2. Systolic blood pressure >109 mm Hg
  3. Pulse <100/minute
  4. Blood urea nitrogen level <18.2 mg/dL
  5. No melena or syncope
  6. No past or present liver disease or heart failure

Bayesian calculation

The predictive values cited are based on the prevalences of upper gastrointestinal bleeding in the corresponding studies. A clinical calculator can be used to generate predictive values for other prevalences.[ citation needed ]

Treatment

The initial focus is on resuscitation beginning with airway management and fluid resuscitation using either intravenous fluids and or blood. [15] A number of medications may improve outcomes depending on the source of the bleeding. [15] Proton pump inhibitor medications are often given in the emergent setting before an endoscopy and may reduce the need for an endoscopic haemotstatic treatment. [16] Proton pump inhibitors decrease gastric acid production. [16] There is insufficient evidence to determine if proton pump inhibitors decrease death rates, re-bleeding events, or the need for surgical interventions. [16] After the initial resuscitation has been completed, treatment is instigated to limit the likelihood of re-bleeds and correct any anemia that the bleeding may have caused. Those with a Glasgow Blatchford score less than 2 may not require admission to hospital. [17]

Peptic ulcers

Based on evidence from people with other health problems crystalloid and colloids are believed to be equivalent for peptic ulcer bleeding. [15] In people with a confirmed peptic ulcer, proton pump inhibitors do not reduce death rates, later bleeding events, or need for surgery. [18] They may decrease signs of bleeding at endoscopy however. [18] In those with less severe disease and where endoscopy is rapidly available, they are of less immediate clinical importance. [16] Tranexamic acid might be effective to reduce mortality, but the evidence for this is weak. [15] [19] But the evidence is promising. [20] Somatostatin and octreotide while recommended for variceal bleeding have not been found to be of general use for non-variceal bleeds. [15]

Variceal bleeding

For initial fluid replacement colloids or albumin is preferred in people with cirrhosis. [15] Medications typically includes octreotide or if not available vasopressin and nitroglycerin to reduce portal pressures. [21] This is typically in addition to endoscopic banding or sclerotherapy for the varices. [21] If this is sufficient then beta blockers and nitrates may be used for the prevention of re-bleeding. [21] If bleeding continues then balloon tamponade with a Sengstaken-Blakemore tube or Minnesota tube may be used in an attempt to mechanically compress the varices. [21] This may then be followed by a transjugular intrahepatic portosystemic shunt. [21]

Blood products

If large amounts of pack red blood cells are used additional platelets and fresh frozen plasma should be administered to prevent coagulopathies. [15] Some evidence supports holding off on blood transfusions in those who have a hemoglobin greater than 7 to 8 g/dL and only moderate bleeding. [15] [22] If the INR is greater than 1.5 to 1.8 correction with fresh frozen plasma, prothrombin complex may decrease mortality. [15]

Procedures

The above ulcer seen after endoscopic clipping GU with clip.jpg
The above ulcer seen after endoscopic clipping

Upper endoscopy within 24 hours is the recommended treatment. [15] [23] The benefits versus risks of placing a nasogastric tube in those with upper gastrointestinal bleeding are not well known. [15] Prokinetic agents to empty thee stomach such as erythromycin before endoscopy can decrease the amount of blood in the stomach and thus improve the operators view. [15] This erythromycin treatment may lead to a small decrease in the need for a blood transfusion, but the overall balance of how effective erythromycin is compared to potential risks is not clear. [15] [23] Proton pump inhibitors, if they have not been started earlier, are recommended in those in whom high risk signs for bleeding are found. [15] It is also recommended that people with high risk signs are kept in hospital for at least 72 hours. [15] Blood transfusions are not generally recommended to correct anemia, but blood transfusions are recommended if the person is not stable (cardiovascular system instability). [22] Oral iron can be used, but this can lead to problems with compliance, tolerance, darkening stools which may mask evidence of rebleeding and tends to be slow, especially if used in conjunction with proton pump inhibitors. Parenteral Iron is increasingly used in these cases to improve patient outcomes and void blood usage.[ citation needed ]

Prognosis

Depending on its severity, upper gastrointestinal bleeding may carry an estimated mortality risk of 11%. [3] However, survival has improved to about 2 percent, likely as a result of improvements in medical therapy and endoscopic control of bleeding. [24]

Epidemiology

About 75% of people presenting to the emergency department with gastrointestinal bleeding have an upper source. [9] The diagnosis is easier when the people have hematemesis. In the absence of hematemesis, 40% to 50% of people in the emergency department with gastrointestinal bleeding have an upper source. [8] [10] [25]

See also

Related Research Articles

Peptic ulcer disease is a break in the inner lining of the stomach, the first part of the small intestine, or sometimes the lower esophagus. An ulcer in the stomach is called a gastric ulcer, while one in the first part of the intestines is a duodenal ulcer. The most common symptoms of a duodenal ulcer are waking at night with upper abdominal pain, and upper abdominal pain that improves with eating. With a gastric ulcer, the pain may worsen with eating. The pain is often described as a burning or dull ache. Other symptoms include belching, vomiting, weight loss, or poor appetite. About a third of older people with peptic ulcers have no symptoms. Complications may include bleeding, perforation, and blockage of the stomach. Bleeding occurs in as many as 15% of cases.

Hematemesis is the vomiting of blood. It can be confused with hemoptysis or epistaxis (nosebleed), which are more common. The source is generally the upper gastrointestinal tract, typically above the suspensory muscle of duodenum. It may be caused by ulcers, tumors of the stomach or esophagus, varices, prolonged and vigorous retching, gastroenteritis, ingested blood, or certain drugs.

Melena or melaena refers to the dark black, tarry feces that are associated with upper gastrointestinal bleeding. The black color and characteristic strong odor are caused by hemoglobin in the blood being altered by digestive enzymes and intestinal bacteria.

Coffee ground vomitus refers to a particular appearance of vomit. Within organic heme molecules of red blood cells is the element iron, which oxidizes following exposure to gastric acid. This reaction causes the vomitus to look like ground coffee.

<span class="mw-page-title-main">Esophagogastroduodenoscopy</span> Diagnostic endoscopic procedure

Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered a minimally invasive procedure since it does not require an incision into one of the major body cavities and does not require any significant recovery after the procedure. However, a sore throat is common.

<span class="mw-page-title-main">Esophageal varices</span> Medical condition

Esophageal varices are extremely dilated sub-mucosal veins in the lower third of the esophagus. They are most often a consequence of portal hypertension, commonly due to cirrhosis. People with esophageal varices have a strong tendency to develop severe bleeding which left untreated can be fatal. Esophageal varices are typically diagnosed through an esophagogastroduodenoscopy.

<span class="mw-page-title-main">Dieulafoy's lesion</span> Medical condition

Dieulafoy's lesion is a medical condition characterized by a large tortuous artery most commonly in the stomach wall (submucosal) that erodes and bleeds. It can present in any part of the gastrointestinal tract. It can cause gastric hemorrhage but is relatively uncommon. It is thought to cause less than 5% of all gastrointestinal bleeds in adults. It was named after French surgeon Paul Georges Dieulafoy, who described this condition in his paper "Exulceratio simplex: Leçons 1-3" in 1898. It is also called "caliber-persistent artery" or "aneurysm" of gastric vessels. However, unlike most other aneurysms, these are thought to be developmental malformations rather than degenerative changes.

<span class="mw-page-title-main">Gastrointestinal bleeding</span> Medical condition

Gastrointestinal bleeding, also called gastrointestinal hemorrhage (GIB), is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool. Small amounts of bleeding over a long time may cause iron-deficiency anemia resulting in feeling tired or heart-related chest pain. Other symptoms may include abdominal pain, shortness of breath, pale skin, or passing out. Sometimes in those with small amounts of bleeding no symptoms may be present.

<span class="mw-page-title-main">Gastric varices</span> Medical condition

Gastric varices are dilated submucosal veins in the lining of the stomach, which can be a life-threatening cause of bleeding in the upper gastrointestinal tract. They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis. Gastric varices may also be found in patients with thrombosis of the splenic vein, into which the short gastric veins that drain the fundus of the stomach flow. The latter may be a complication of acute pancreatitis, pancreatic cancer, or other abdominal tumours, as well as hepatitis C. Gastric varices and associated bleeding are a potential complication of schistosomiasis resulting from portal hypertension.

Rectal bleeding refers to bleeding in the rectum. There are many causes of rectal hemorrhage, including inflamed hemorrhoids, rectal varices, proctitis, stercoral ulcers and infections. Diagnosis is usually made by proctoscopy, which is an endoscopic test.

<span class="mw-page-title-main">Gastric antral vascular ectasia</span> Medical condition of the stomach

Gastric antral vascular ectasia (GAVE) is an uncommon cause of chronic gastrointestinal bleeding or iron deficiency anemia. The condition is associated with dilated small blood vessels in the gastric antrum, which is a distal part of the stomach. The dilated vessels result in intestinal bleeding. It is also called watermelon stomach because streaky long red areas that are present in the stomach may resemble the markings on watermelon.

<span class="mw-page-title-main">Balloon tamponade</span>

Balloon tamponade is the use of balloons inserted into the esophagus, stomach or uterus, and inflated to alleviate or stop refractory bleeding.

<span class="mw-page-title-main">Sengstaken–Blakemore tube</span> Medical device

A Sengstaken–Blakemore tube is a medical device inserted through the nose or mouth and used occasionally in the management of upper gastrointestinal hemorrhage due to esophageal varices. The use of the tube was originally described in 1950, although similar approaches to bleeding varices were described by Westphal in 1930. With the advent of modern endoscopic techniques which can rapidly and definitively control variceal bleeding, Sengstaken–Blakemore tubes are rarely used at present.

<span class="mw-page-title-main">Hemosuccus pancreaticus</span> Medical condition

Hemosuccus pancreaticus is a rare cause of hemorrhage in the gastrointestinal tract. It is caused by a bleeding source in the pancreas, pancreatic duct, or structures adjacent to the pancreas, such as the splenic artery, that bleed into the pancreatic duct, which is connected with the bowel at the duodenum, the first part of the small intestine. Patients with hemosuccus may develop symptoms of gastrointestinal hemorrhage, such as blood in the stools, maroon stools, or melena, which is a dark, tarry stool caused by digestion of red blood cells. They may also develop abdominal pain. It is associated with pancreatitis, pancreatic cancer and aneurysms of the splenic artery. Hemosuccus may be identified with endoscopy (esophagogastroduodenoscopy), where fresh blood may be seen from the pancreatic duct. Alternatively, angiography may be used to inject the celiac axis to determine the blood vessel that is bleeding. This may also be used to treat hemosuccus, as embolization of the end vessel may terminate the hemorrhage. However, a distal pancreatectomy—surgery to remove of the tail of the pancreas—may be required to stop the hemorrhage.

A stress ulcer is a single or multiple mucosal defect usually caused by physiological stress which can become complicated by upper gastrointestinal bleeding. These ulcers can be caused by shock, sepsis, trauma or other conditions and are found in patients with chronic illnesses. These ulcers are a significant issue in patients in critical and intensive care.

<span class="mw-page-title-main">Portal hypertensive gastropathy</span> Changes in the mucosa of the stomach in patients with portal hypertension

Portal hypertensive gastropathy refers to changes in the mucosa of the stomach in patients with portal hypertension; by far the most common cause of this is cirrhosis of the liver. These changes in the mucosa include friability of the mucosa and the presence of ectatic blood vessels at the surface. Patients with portal hypertensive gastropathy may experience bleeding from the stomach, which may uncommonly manifest itself in vomiting blood or melena; however, portal hypertension may cause several other more common sources of upper gastrointestinal bleeding, such as esophageal varices and gastric varices. On endoscopic evaluation of the stomach, this condition shows a characteristic mosaic or "snake-skin" appearance to the mucosa of the stomach.

<span class="mw-page-title-main">Butyl cyanoacrylate</span> Chemical compound

n-Butyl cyanoacrylate, a cyanoacrylate ester, is a butyl ester of 2-cyano-2-propenoic acid. It is a colorless liquid with a sharp, irritating odor. It is insoluble in water. Its chief use is as the main component of medical cyanoacrylate glues. It can be encountered under various trade names, e.g. Cutseal, MediBond, MediCryl, PeriAcryl, GluStitch, Xoin, Gesika, VetGlu, Vetbond, LiquiVet, Indermil, LiquiBand, Histoacryl, IFABond, CutisSeal and others. The generic international nonproprietary name (INN) for NBCA is enbucrilate.

Therapeutic endoscopy is the medical term for an endoscopic procedure during which treatment is carried out via the endoscope. This contrasts with diagnostic endoscopy, where the aim of the procedure is purely to visualize a part of the gastrointestinal, respiratory or urinary tract in order to aid diagnosis. In practice, a procedure which starts as a diagnostic endoscopy may become a therapeutic endoscopy depending on the findings, such as in cases of upper gastrointestinal bleeding, or the finding of polyps during colonoscopy.

A Cameron lesion is a linear erosion or ulceration of the mucosal folds lining the stomach where it is constricted by the thoracic diaphragm in persons with large hiatal hernias. The lesions may cause chronic blood loss resulting in iron deficiency anemia; less often they cause acute bleeding.

Hemostatic Powder Spray TC-325 is an inert, highly absorptive mineral agent which is used for the treatment of gastrointestinal bleeding. Applied during endoscopy to bleeding lesions, TC-325 is derived from bentonite, and is used to achieve hemostasis by absorbing water and creating a barrier that leads to mechanical tamponade (pressure) and concentration of clotting factors, resulting in enhanced coagulation. TC-325 was approved for gastrointestinal bleeding from causes other than gastric or esophageal varices. TC-325 results in immediate control of bleeding in 91-93% of cases. Technical success has gradually increased between 2011 and 2019, which may be due to device improvements or physician familiarity with the application of TC-325.

References

  1. ↑ Barkun, AN; Almadi, M; Kuipers, EJ; Laine, L; Sung, J; Tse, F; Leontiadis, GI; Abraham, NS; Calvet, X; Chan, FKL; Douketis, J; Enns, R; Gralnek, IM; Jairath, V; Jensen, D; Lau, J; Lip, GYH; Loffroy, R; Maluf-Filho, F; Meltzer, AC; Reddy, N; Saltzman, JR; Marshall, JK; Bardou, M (22 October 2019). "Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group". Annals of Internal Medicine. 171 (11): 805–822. doi: 10.7326/M19-1795 . PMC   7233308 . PMID   31634917.
  2. 1 2 3 Beyda, R; Johari, D (22 July 2019). "Tranexamic acid for upper gastrointestinal bleeding". Academic Emergency Medicine. 26 (10): 1181–1182. doi: 10.1111/acem.13835 . PMID   31329328.
  3. 1 2 British Society of Gastroenterology Endoscopy Committee (October 2002). "Non-variceal upper gastrointestinal haemorrhage: guidelines". Gut. 51 (Suppl 4): iv1–6. doi:10.1136/gut.51.suppl_4.iv1. PMC   1867732 . PMID   12208839.
  4. ↑ "Are SSRIs associated with upper gastrointestinal bleeding in adults?". Global Family Doctor. Archived from the original on 2011-07-11. Retrieved 2010-11-24.
  5. ↑ Graber CJ, et al. (2007). "A Stitch in Time — A 64-year-old man with a history of coronary artery disease and peripheral vascular disease was admitted to the hospital with a several-month history of fevers, chills, and fatigue". N Engl J Med. 357 (10): 1029–34. doi:10.1056/NEJMcps062601. PMID   17804848.
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  11. ↑ Rosenthal P, Thompson J, Singh M; Thompson; Singh (1984). "Detection of occult blood in gastric juice". J. Clin. Gastroenterol. 6 (2): 119–21. doi:10.1097/00004836-198404000-00004. PMID   6715849.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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  13. ↑ Stanley AJ, Ashley D, Dalton HR, et al. (January 2009). "Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation". Lancet. 373 (9657): 42–7. doi:10.1016/S0140-6736(08)61769-9. PMID   19091393. S2CID   1738579.
  14. ↑ "Glasgow-Blatchford bleeding score" . Retrieved 2009-01-24.
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  16. 1 2 3 4 Kanno, Takeshi; Yuan, Yuhong; Tse, Frances; Howden, Colin W.; Moayyedi, Paul; Leontiadis, Grigorios I. (2022-01-07). "Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding". The Cochrane Database of Systematic Reviews. 1 (1): CD005415. doi:10.1002/14651858.CD005415.pub4. ISSN   1469-493X. PMC   8741303 . PMID   34995368.
  17. ↑ Barkun, Alan N.; Almadi, Majid; Kuipers, Ernst J.; Laine, Loren; Sung, Joseph; Tse, Frances; Leontiadis, Grigorios I.; Abraham, Neena S.; Calvet, Xavier; Chan, Francis K.L.; Douketis, James; Enns, Robert; Gralnek, Ian M.; Jairath, Vipul; Jensen, Dennis; Lau, James; Lip, Gregory Y.H.; Loffroy, Romaric; Maluf-Filho, Fauze; Meltzer, Andrew C.; Reddy, Nageshwar; Saltzman, John R.; Marshall, John K.; Bardou, Marc (22 October 2019). "Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group". Annals of Internal Medicine. 171 (11): 805–822. doi: 10.7326/M19-1795 . PMC   7233308 . PMID   31634917.
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  19. ↑ Bennett, Cathy; Klingenberg, Sarah Louise; Langholz, Ebbe; Gluud, Lise Lotte (2014-11-21). "Tranexamic acid for upper gastrointestinal bleeding". The Cochrane Database of Systematic Reviews. 2014 (11): CD006640. doi:10.1002/14651858.CD006640.pub3. ISSN   1469-493X. PMC   6599825 . PMID   25414987.
  20. ↑ Gluud, LL; Klingenberg, SL, Langholz, SE (May 2008). "Systematic review: tranexamic acid for upper gastrointestinal bleeding". Alimentary Pharmacology & Therapeutics. 27 (9): 752–8. doi: 10.1111/j.1365-2036.2008.03638.x . PMID   18248659. S2CID   24594884.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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  22. 1 2 Villanueva, Càndid; Colomo, Alan; Bosch, Alba; Concepción, Mar; Hernandez-Gea, Virginia; Aracil, Carles; Graupera, Isabel; Poca, María; et al. (2013). "Transfusion Strategies for Acute Upper Gastrointestinal Bleeding". New England Journal of Medicine. 368 (1): 11–21. doi: 10.1056/NEJMoa1211801 . PMID   23281973.
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  24. ↑ Cai, Jennifer X.; Saltzman, John R. (July 2018). "Initial Assessment, Risk Stratification, and Early Management of Acute Nonvariceal Upper Gastrointestinal Hemorrhage". Gastrointestinal Endoscopy Clinics of North America. 28 (3): 261–275. doi:10.1016/j.giec.2018.02.001. PMID   29933774. S2CID   49377957.
  25. ↑ Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M; Magder; Heins; Mattu; Granja; Baumgarten (2004). "Usefulness and validity of diagnostic nasogastric aspiration in patients without hematemesis". Ann Emerg Med. 43 (4): 525–32. doi:10.1016/j.annemergmed.2003.09.002. PMID   15039700.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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