Most Common Site of Bleeding in Upper GI Bleeding
Peptic ulcer disease is the most common site of bleeding in upper gastrointestinal bleeding, with gastric ulcers accounting for 32% and duodenal ulcers accounting for 28% of nonvariceal cases. 1, 2
Primary Bleeding Sites in Upper GI Bleeding
Peptic Ulcer Disease (Most Common)
- Gastric ulcers represent 32% of nonvariceal upper GI bleeding cases 1, 2
- Duodenal ulcers account for 28% of cases 1, 2
- Combined, peptic ulcer disease accounts for approximately 60% of all nonvariceal upper GI bleeding and about 50% of all upper GI bleeding cases when including variceal causes 3, 4, 5, 6
- The primary etiologies are Helicobacter pylori infection and NSAID/aspirin use 3, 1, 2, 6
Other Nonvariceal Sources
- Esophageal varices represent 9% of upper GI bleeding cases, though this percentage is higher in populations with significant cirrhosis and portal hypertension 1
- Mallory-Weiss tears, esophagitis, and gastritis account for smaller percentages of cases 3, 4
- Rare but critical causes include hemobilia, hemosuccus pancreaticus (approximately 1 in 500 cases), and aortoenteric fistula 3, 1, 2
Geographic and Population Variations
Important caveat: The distribution of bleeding sites varies significantly by geographic region and patient population:
- In Western countries like the United States, peptic ulcer disease dominates as the leading cause 3, 1, 6
- In tropical countries like India, esophageal varices may account for up to 50% of cases, particularly in populations with high rates of alcoholic cirrhosis 7
- The incidence of nonvariceal upper GI bleeding (61-78 cases per 100,000 persons) is approximately 4-5 times higher than variceal bleeding 3, 1
Clinical Implications for Diagnosis
- Approximately 10-15% of patients presenting with severe hematochezia (bright red blood per rectum) actually have an upper GI source, emphasizing the need to consider peptic ulcer disease even with atypical presentations 1, 2
- An elevated BUN-to-creatinine ratio helps distinguish upper from lower GI bleeding, as blood in the upper GI tract is digested and absorbed as protein 8
- Risk factors that increase suspicion for peptic ulcer bleeding include prior peptic ulcer disease history, NSAID use, antiplatelet drug use, and older age 2, 8, 4