What are the causes and management of upper gastrointestinal bleeding (UGIB) and hematemesis?

Causes of Upper Gastrointestinal Bleeding and Hematemesis

Peptic ulcer disease is the leading cause of upper GI bleeding, accounting for 35-50% of cases, followed by gastroduodenal erosions (8-15%), Mallory-Weiss tears (15%), esophagitis (5-15%), and varices (5-10%). 1

Common Etiologies

Non-Variceal Causes (Most Frequent)

• Peptic ulcer disease (duodenal and gastric ulcers) represents 50-70% of all non-variceal upper GI bleeding cases, primarily related to Helicobacter pylori infection or NSAID use 2, 3

• Gastroduodenal erosions and stress-related mucosal disease occur in 8-15% of cases, particularly prevalent in critically ill patients with mechanical ventilation, coagulopathy, or renal failure 1, 2

• Mallory-Weiss tears account for approximately 15% of cases, resulting from forceful vomiting or retching 1, 2

• Esophagitis causes 5-15% of upper GI bleeding episodes 1, 3

Variceal Causes

• Esophageal varices represent 5-10% of cases, occurring predominantly in patients with cirrhosis 1, 2

Less Common but Important Causes

• Upper GI malignancies including gastric cancer and hepatocellular carcinoma eroding into the duodenum 2

• Vascular malformations and angiodysplasia account for approximately 1% of cases 1, 2

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

Rare but Critical Etiologies

• Hemosuccus pancreaticus is responsible for approximately 1 in 500 cases of upper GI bleeding, representing the most common pancreatic cause 2, 4

• Hemobilia (bleeding into the biliary tree) is a rare but important consideration 2

• Aortoenteric fistula is rare but potentially catastrophic 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

Clinical Presentation Definitions

• Hematemesis is vomiting fresh red blood 1

• Coffee ground vomiting is vomiting of altered black blood 1

• Melena is the passage of black tarry stools 1

• Hemochezia (passage of red blood per rectum) usually indicates lower GI bleeding but can occur with massive upper GI bleeding 1

Critical Clinical Context

Patients presenting with both hematemesis and melena have more severe bleeding than those with melena alone. 1

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

• A cause for upper GI bleeding is identified in approximately 80% of cases 1

• Mortality is 11% in patients admitted specifically for bleeding and 33% in those who develop bleeding while hospitalized for other reasons 1