Causes of Upper Gastrointestinal Bleeding

Upper GI bleeding is defined as that originating proximal to the ligament of Treitz, whereas lower GI bleeding originates more distally.

PEPTIC ULCER DISEASE Peptic ulcer disease, including gastric, duodenal, and stomal ulcers, remains the most common etiology for upper GI hemorrhage, encompassing approximately 60 percent of all cases.2 Duodenal ulcers, approximately 29 percent of the total, will rebleed in approximately 10 percent of cases, usually within 24 to 48 h. Gastric ulcers, approximately 16 percent of all cases, are more likely to rebleed. Stomal ulcers are uncommon (less than 5 percent of all upper GI bleeds) and are present in only one-third of bleeding patients with a history of prior peptic ulcer surgery.

EROSIVE GASTRITIS AND ESOPHAGITIS Erosive gastritis, esophagitis, and duodenitis together are responsible for approximately 15 percent of all cases of upper GI hemorrhage. Irritative factors, such as alcohol, salicylates, and nonsteroidal anti-inflammatory agents, are predisposing factors.

ESOPHAGEAL AND GASTRIC VARICES Esophageal and gastric varices result from portal hypertension and, in the United States, are most often a result of alcoholic liver disease. Although varices account for only about 6 percent of all cases of upper Gi hemorrhage, they are highly likely to rebleed and carry a high mortality rate. Despite this, many patients with end-stage cirrhosis never develop varices, many patients with documented varices never bleed, and many patients with a documented history of varices presenting with upper GI bleeding will be bleeding from nonvariceal sites.

MALLORY-WEISS SYNDROME The Mallory-Weiss syndrome is upper GI bleeding secondary to a longitudinal mucosal tear in the cardioesophageal region. The classic history is repeated retching followed by bright red hematemesis, but coughing and seizures have also been reported as etiologic factors.

OTHER ETIOLOGIES Stress ulcer, arteriovenous malformation, and malignancy are other etiologies of upper GI hemorrhage. ENT (ear, nose, and throat) sources of bleeding can also masquerade as GI hemorrhage. An aortoenteric fistula secondary to an aortic graft is an unusual but important cause of bleeding to keep in mind. Classically, this will present as a self-limited "herald" bleed preceding a subsequent massive hemorrhage.

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