What are the major causes of upper gastrointestinal bleeding (UGIB)?

Updated: Sep 01, 2021
  • Author: Bennie Ray Upchurch, III, MD, FACP, AGAF, FACG, FASGE; Chief Editor: BS Anand, MD  more...
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Other major causes of UGIB are mucosal tears of the esophagus or fundus (Mallory-Weiss tear), erosive gastritis, erosive esophagitis, Dieulafoy lesion, gastric cancer, and ulcerated gastric leiomyoma.

Patients with chronic liver disease and portal hypertension are at an increased risk for variceal hemorrhage and portal gastropathy in addition to ulcer hemorrhage.

Rare causes of UGIB include aortoenteric fistula, gastric antral vascular ectasia, angiectasias, and Osler-Weber-Rendu syndrome.

An aortoenteric fistula results from the erosion of the aortic graft into the bowel lumen, usually at the third or fourth portion of the duodenum. The result is a direct communication between the aortic graft lumen and the bowel lumen. Most aortoenteric fistulas involve the proximal aortic anastomotic suture line.

 Acute stress-related mucosal disease (also known as stress ulcers), a disease process characterized by diffuse superficial mucosal erosions that appear as discrete areas of erythema, can also cause UGIB. [16] The bleeding is usually mild and self-limiting and rarely progresses to life-threatening hemorrhage. Stress ulcers can be detected endoscopically in as many as 75%-100% of critically ill patients, within 24 hours of admission to an intensive care unit (ICU).

In ICU patients, the incidence of clinically significant GI bleeding (eg, hypotension, transfusion) from acute stress ulcer was found to be 1.5%. [18]  Although its incidence has fallen significantly over recent decades, likely due to better overall ICU care, mortality remains high in those with clinically important bleeding. [19] Stress ulcers are historically associated with (1) head injuries, with related elevations in intracranial pressure (Cushing ulcers) and (2) burn injuries (Curling ulcers).

Critically ill patients are at an increased risk of developing stress-related mucosal disease and subsequent stress-ulcer bleeding, most commonly with risk factors of respiratory failure and coagulopathy. [20] Other important factors include acute renal or hepatic failure, sepsis, hypotension, severe head or spinal cord injury, severe burns, acute lung injury, major or prolonged surgery, and a history of GI bleeding. [21]

Angiodysplasia of the upper GI tract accounts for 2%-4% of bleeding lesions. [10] The condition is also a cause of lower GI bleeding in 6% of cases. [16] The lesion is a vascular malformation that represents an abnormal dilation of mucosal and submucosal vessels.

Histologically, angiodysplasias are dilated, thin-walled vascular channels that appear macroscopically as a cluster of cherry spots. When located in the upper GI tract, they most commonly involve the stomach and duodenum. The lesions can be acquired or congenital, as in hereditary hemorrhagic telangiectasia and Osler-Weber-Rendu syndrome.

The acquired angiodysplasias are commonly found in patients with chronic renal failure requiring hemodialysis and with aortic valvular disease (especially aortic stenosis due to Heyde syndrome). Other diseases, such as cirrhosis and von Willebrand disease, are associated with a higher frequency of angiodysplasias. Most lesions are smaller than 1 cm in diameter and can be multiple in 66% of patients. [10]

For patient education information, see the Digestive Disorders Center and the Heartburn and GERD Center, as well as the patient education article Gastrointestinal Bleeding (GI Bleeding).

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