Differential Diagnoses for Hematin Throughout Stomach and Erythema/Hematin in Proximal Duodenum
The most likely diagnoses are peptic ulcer disease (gastric or duodenal ulcers), erosive gastritis/duodenitis, or Mallory-Weiss tear, with peptic ulcer disease being the most common cause accounting for approximately 60% of nonvariceal upper GI bleeding cases. 1, 2
Primary Differential Diagnoses
Most Common Causes
Peptic ulcer disease represents the leading cause, with gastric ulcers accounting for 32% and duodenal ulcers for 28% of nonvariceal upper GI bleeding cases, primarily related to Helicobacter pylori infection or NSAID use 2
Erosive gastritis/duodenitis is a frequent cause, particularly in critically ill patients, those with NSAID/aspirin use, or alcohol consumption 3, 4
Mallory-Weiss tears account for approximately 7.5% of upper GI bleeding cases and should be considered, especially with a history of retching or vomiting 4
Less Common but Important Causes
Esophagitis can present with hematin and represents 2.5% of cases, though typically causes more proximal symptoms 4
Duodenal hemangioma is a rare benign vascular tumor that can cause significant bleeding and requires direct visualization for diagnosis 5
Neoplastic lesions including gastric carcinoma account for approximately 2.5% of cases and must be excluded 4
Rare but Catastrophic Causes
Hemosuccus pancreaticus is responsible for approximately 1 in 500 cases of upper GI bleeding and should be considered if other causes are excluded 6
Aortoenteric fistula is rare but potentially fatal, particularly in patients with prior aortic surgery or grafts 1, 2
Hemobilia should be considered in patients with recent hepatobiliary procedures or trauma 1
Critical Clinical Considerations
Risk Stratification Factors
Look for specific risk factors including history of peptic ulcer disease, portal hypertension, elevated BUN/creatinine ratio, antiplatelet drug use, and NSAID consumption 7
Assess hemodynamic stability immediately, as approximately 10-15% of patients with severe hematochezia actually have an upper GI source despite presenting with bright red blood per rectum 1, 2
Common Pitfall to Avoid
- Do not assume lower GI source based solely on hematochezia presentation - up to 15% of patients with serious hematochezia have an upper GI source identified at upper endoscopy, particularly those with hemodynamic instability, hemoglobin drop ≥1.5 g/dL, or transfusion requirement 1
Diagnostic Approach Algorithm
Immediate Assessment
Perform nasogastric lavage if medium to low suspicion of upper GI source; presence of blood, clots, or coffee-ground material mandates upper endoscopy 1
Check BUN/creatinine ratio as elevated ratio distinguishes upper from lower GI bleeding due to blood digestion and urea nitrogen absorption 7
Endoscopic Evaluation
Esophagogastroduodenoscopy is first-line for both diagnosis and therapy in hemodynamically stable patients 1
Provide airway protection via intubation prior to endoscopy in patients with large-volume bleeding 1
If Endoscopy is Negative or Contraindicated
CT angiography has 70.9% sensitivity and 73.7% specificity in high-risk patients requiring ≥500 mL transfusion, with contrast extravasation being the most specific sign 1
Consider CT enterography to identify potential bleeding sources such as small-bowel neoplasms, angiodysplasia, or Meckel diverticulum when bleeding is slow or obscure 1