Differential Diagnosis for Upper Gastrointestinal Bleeding (UGIB)
Peptic ulcer disease is the most common cause of UGIB, accounting for 35-50% of cases, followed by gastroduodenal erosions, Mallory-Weiss tears, esophagitis, and varices. 1
Primary Causes (in order of frequency)
Most Common Causes
Peptic ulcer disease (35-50%): Includes both gastric and duodenal ulcers, with major risk factors being Helicobacter pylori infection and NSAID use 1, 2
Mallory-Weiss tear (15%): Mucosal tear at the gastroesophageal junction, typically following forceful vomiting 1
Gastroduodenal erosions (8-15%): Superficial mucosal injury often related to NSAIDs, alcohol, or stress 1
Esophagitis (5-15%): Erosive inflammation of the esophageal mucosa 1
Varices (5-10%): Dilated submucosal veins in the esophagus or stomach, typically in patients with portal hypertension from liver disease 1
Less Common but Important Causes
Upper gastrointestinal malignancy: Includes gastric cancer and other GI tract tumors 1, 3
Vascular malformations (1%): Includes arteriovenous malformations and angiodysplasia 1, 4
Dieulafoy lesion: Large caliber aberrant submucosal artery that erodes through the mucosa 2, 5
Gastric antral vascular ectasia (GAVE): Also known as "watermelon stomach" 2
Rare Causes (approximately 5%)
Hemobilia: Bleeding from the biliary tree into the GI tract 2
Aortoenteric fistula: Abnormal connection between the aorta and GI tract, often in patients with prior aortic surgery 2, 5
Trauma or iatrogenic causes: Post-procedural bleeding or traumatic injury 5
Ischemic injury: Mucosal ischemia from vascular insufficiency 5
Key Clinical Context
In approximately 80% of cases, a definitive bleeding source is identified, while 20% remain without a clear diagnosis. 1 The specific cause significantly impacts prognosis and management strategy, with active arterial bleeding from peptic ulcers in shocked patients carrying an 80% risk of continued bleeding or death, while clean-based ulcers or Mallory-Weiss tears have very low rebleeding risk. 1
Peptic ulcer disease has historically been and remains the leading cause of UGIB, contrary to some earlier suggestions that gastritis had become more common. 6 When endoscopy identifies the bleeding source, peptic ulcer disease accounts for approximately 75% of cases. 6