What are the causes of upper gastrointestinal (GI) bleed?

Causes of Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding is most commonly caused by peptic ulcer disease (35-50%), followed by gastroduodenal erosions (8-15%), Mallory-Weiss syndrome (15%), esophagitis (5-15%), esophageal varices (5-10%), and vascular malformations (1%). 1

Common Causes of Upper GI Bleeding

Non-variceal Causes

• Peptic ulcer disease - Most common cause (35-50%)
  • Risk factors: H. pylori infection, NSAID use 1, 2
• Gastroduodenal erosions (8-15%)
  • Often associated with NSAID use, stress, or alcohol consumption 1
• Mallory-Weiss tears (15%)
  • Characterized by longitudinal mucosal tears at the gastroesophageal junction 1
• Esophagitis (5-15%)
  • Usually due to gastroesophageal reflux disease 1, 2
• Vascular malformations (1%)
  • Including angiodysplasia 1
• Neoplasms (gastric or esophageal cancer) 3

Variceal Causes

• Esophageal varices (5-10%)
  • Associated with portal hypertension, typically from liver cirrhosis 1, 4
• Gastric varices
  • Less common than esophageal varices but can cause severe bleeding 4, 5
• Portal hypertensive gastropathy
  • Mucosal changes in the stomach due to portal hypertension 4, 5

Less Common Causes

• Dieulafoy lesion - An underrecognized but serious cause accounting for 1-2% of cases 3
• Hemobilia - Bleeding from the biliary tract 3, 1
• Hemosuccus pancreaticus - Bleeding from the pancreatic duct, estimated to be responsible for 1 in 500 cases of UGIB 3, 1
• Aortoenteric fistula - Rare but potentially catastrophic 3
• Iatrogenic causes:
  • Endoscopic ultrasound-guided biopsies 3, 1
  • Endoscopic retrograde cholangiopancreatography-related injury 3
  • Complications from biliary metallic stenting 3
  • Complications from esophageal or upper GI stent placement 3
  • Extrahepatic arterial injury after pancreatic surgery 3

Risk Factors for Upper GI Bleeding

• Advanced age
• Prior history of upper GI bleeding
• Anticoagulant use
• High-dose NSAID use
• H. pylori infection
• Alcohol consumption
• Smoking
• Pre-existing liver disease 1, 2

Clinical Presentation

• Hematemesis (vomiting of blood)
• Melena (black, tarry stools) - typically requires at least 50-100 mL of blood 1
• Hematochezia (bright red blood per rectum) - can occur with massive upper GI bleeding 1
• Associated symptoms may include abdominal pain, lightheadedness, dizziness, and syncope 2

Important Clinical Considerations

• Upper GI bleeding ceases spontaneously in approximately 75-85% of cases, but mortality remains significant (up to 14% in some studies) 3, 1
• Not all black stools indicate melena - certain medications (such as iron) and foods (such as licorice) can cause similar appearance 1
• Massive upper GI bleeding can present with hematochezia rather than melena due to rapid transit time 1
• Endoscopy is the gold standard for diagnosis, with a diagnostic yield of up to 95% when performed within 24 hours of presentation 1

Understanding these causes is essential for prompt diagnosis and appropriate management of upper GI bleeding to reduce morbidity and mortality.