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

Causes of Upper Gastrointestinal Bleeding

Peptic ulcer disease is the leading cause of upper GI bleeding, accounting for 50-70% of all nonvariceal cases, primarily related to Helicobacter pylori infection or NSAID use. 1, 2

Primary Causes (Nonvariceal)

Most Common Etiologies

• Peptic ulcer disease (duodenal and gastric ulcers) represents the dominant cause, responsible for 50-70% of all nonvariceal upper GI bleeding cases 1, 2

  • H. pylori infection and NSAID use are the primary underlying mechanisms 1, 2

• Gastric erosions and stress-related mucosal disease are particularly prevalent in critically ill patients with risk factors including mechanical ventilation, coagulopathy, and renal failure 2

• Esophagitis is an important inflammatory cause of upper GI bleeding 1, 2

• Mallory-Weiss tears result from forceful vomiting or retching 2, 3

• Angiodysplasia and vascular malformations represent vascular causes of bleeding 2, 3

Less Common but Important Causes

• Dieulafoy lesion accounts for 1-2% of acute bleeding, consisting of a tortuous submucosal artery penetrating the mucosa, commonly at the posterior gastric wall 2

• Neoplasms, including gastric cancer and hepatocellular carcinoma eroding into the duodenum 2

• Duodenitis as an inflammatory cause 2

Variceal Causes

• Esophageal varices occur more frequently in patients with cirrhosis and represent the most common finding in cirrhotic patients presenting with upper GI bleeding (92.9% in some series) 2, 4

• Gastric varices are found in approximately 33% of cirrhotic patients with upper GI bleeding 4

• Portal hypertensive gastropathy affects approximately 39% of cirrhotic patients with bleeding 4

Rare but Critical Etiologies

• Hemosuccus pancreaticus is responsible for approximately 1 in 500 cases of upper GI bleeding and represents the most common pancreatic cause 2, 5

• Hemobilia (bleeding into the biliary tree) 2

• Aortoenteric fistula is a rare but potentially catastrophic cause 2

ICU-Specific and Iatrogenic Causes

• Endoscopic complications including EUS-guided biopsies, ERCP-related injury, and delayed hemorrhage from biliary metallic stenting 2

• Surgical complications such as extrahepatic arterial injury after pancreatic surgery and stomal marginal ulcers 2

• Esophageal or upper GI stent placement for obstruction 2

Critical Clinical Pitfalls

• Upper GI bleeding ceases spontaneously in 75% of cases but carries a 2-14% mortality risk 2

• Nasogastric aspirate may be negative in 3-16% of patients with confirmed upper GI bleeding, so a negative aspirate does not exclude the diagnosis 2

• In cirrhotic patients, 30-40% may have non-variceal causes (peptic ulcers, portal gastropathy, Mallory-Weiss tears) rather than varices, so endoscopy is essential for accurate diagnosis 4