Differential Diagnosis for Upper Gastrointestinal Bleeding
Most Common Causes
Peptic ulcer disease (PUD) is the most common cause of nonvariceal UGIB, accounting for approximately 50% of cases in the United States, typically related to Helicobacter pylori infection or NSAID use 1.
Primary Nonvariceal Causes (80% of UGIB)
- Peptic ulcer disease (gastric or duodenal ulcers) - most frequent etiology, strongly associated with H. pylori infection and NSAID/antiplatelet drug use 1, 2
- Erosive gastritis/gastropathy - often medication-induced (NSAIDs, aspirin, anticoagulants) or stress-related 1, 3
- Mallory-Weiss tears - mucosal lacerations at the gastroesophageal junction from forceful vomiting or retching 1, 3
- Esophagitis - erosive changes from acid reflux, medications, or infections 1
- Malignancy - gastric or esophageal cancer 1, 3
Variceal Causes (20% of UGIB)
- Esophageal varices - secondary to portal hypertension from cirrhosis 1
- Gastric varices - can occur with or without esophageal varices, often related to splenic vein thrombosis 1
Less Common but Critical Causes
- Dieulafoy's lesion - aberrant submucosal artery that erodes through mucosa 4
- Aortoenteric fistula - rare but catastrophic, consider in patients with prior aortic surgery 1
- Hemobilia - bleeding from biliary tree into duodenum 1
- Hemosuccus pancreaticus - bleeding from pancreatic duct into duodenum 1
- Vascular malformations/angiodysplasia - arteriovenous malformations in gastric or duodenal mucosa 1
Risk Factor-Based Differential Prioritization
Age-Related Considerations
- Patients >70 years: Prioritize peptic ulcer disease, angiodysplasia, and malignancy in the differential 1
- Younger patients: Consider Mallory-Weiss tears, esophagitis, and gastritis more prominently 3
Medication History Impact
- NSAID/aspirin users: Peptic ulcer disease and erosive gastritis are primary considerations 1, 5
- Anticoagulant/antiplatelet therapy: Any mucosal lesion can bleed more severely; peptic ulcers remain most common underlying pathology 1, 5
- Corticosteroid use: Increases risk of peptic ulcer disease 5
Medical History Clues
- Cirrhosis/chronic liver disease: Variceal bleeding becomes the leading consideration (esophageal > gastric varices) 1, 3
- Prior aortic surgery: Aortoenteric fistula must be excluded urgently 1
- Pancreatitis history: Consider hemosuccus pancreaticus 1
- Pelvic radiation (9 months to 4 years prior): Radiation-induced gastritis or duodenitis 1
- Alcohol abuse: Increases likelihood of both variceal bleeding (cirrhosis) and Mallory-Weiss tears 3, 4
Clinical Presentation Patterns
Hematemesis with Hemodynamic Instability
- Primary considerations: Variceal bleeding (66.7% of massive bleeds), bleeding peptic ulcer with visible vessel, aortoenteric fistula 1, 3
- Critical action: These patients require urgent risk stratification and endoscopy within 24 hours after resuscitation 6, 5
Melena Alone
- Typical sources: Peptic ulcer disease, gastritis, duodenitis 6, 3
- Important caveat: Melena can also indicate small bowel bleeding just beyond the ligament of Treitz 1
Hematochezia (Bright Red Blood Per Rectum)
- Consider UGIB when: Patient has hemodynamic instability, elevated BUN/creatinine ratio, or brisk upper GI source 1
- Mechanism: Rapid upper GI bleeding with accelerated transit time 1
Common Diagnostic Pitfalls
Do Not Assume Lower GI Source with Bright Red Blood
- Up to 11% of patients presenting with hematochezia have an upper GI source, particularly when hemodynamically unstable 1
- Elevated blood urea/creatinine ratio suggests upper GI source 1
Nasogastric Tube Placement Not Recommended
- Does not reliably aid diagnosis, does not affect outcomes, and causes complications in up to one-third of patients 1