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Upper GI (UGI) bleeding is defined as bleeding originating proximal to the ligament of Treitz.

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Acute UGI bleeding in adults has an overall annual incidence of approximately 47 per 100,000. It is more common among males and the elderly.1 In contrast, lower GI bleeding is considerably less common.

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As with all true emergencies, the traditional triad of medical history, physical examination, and diagnosis often must be accomplished simultaneously with resuscitation and stabilization. Factors associated with an increased morbidity and mortality are increasing age, coexistent organ system disease, and recurrent hemorrhage.1

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Peptic Ulcer Disease

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Peptic ulcer disease, including gastric, duodenal, esophageal, and stomal ulcers, is the commonest cause of UGI bleeding.1,2

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Erosive Gastritis and Esophagitis

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Erosive gastritis, esophagitis, and duodenitis together are responsible for approximately 13% of all cases of UGI hemorrhage. Predisposing factors include alcohol, salicylates, and NSAIDs.

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Esophageal and Gastric Varices

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Esophageal and gastric varices result from portal hypertension and, in the U.S., are most often a result of alcoholic liver disease. Although varices account for only about 7% of all cases of UGI hemorrhage, they are most likely to rebleed and carry a 16% mortality rate. Nevertheless, many patients with end-stage cirrhosis never develop varices, many patients with documented varices never bleed, and many patients with a documented history of varices presenting with UGI bleeding will actually be bleeding from nonvariceal sites.

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Mallory-Weiss Syndrome

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Mallory-Weiss syndrome is UGI bleeding secondary to a longitudinal mucosal tear in the cardioesophageal region. The classic history is repeated vomiting followed by bright red hematemesis, but extreme Valsalva maneuvers, such as from coughing or seizures, also have been reported as causes.

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Other Causes

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Stress ulcer, arteriovenous malformation, and malignancy are other causes of UGI hemorrhage. Ear, nose, and throat sources of bleeding can also masquerade as GI hemorrhage. An aortoenteric fistula secondary to a preexisting aortic graft is an unusual but important cause of bleeding to keep in mind. Classically, this presents as a self-limited “herald” bleed, which precedes massive hemorrhage.

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Medical History

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Although the medical history may suggest the source of bleeding, it can also be misleading. For instance, what initially appears to be lower GI bleeding is often actually UGI bleeding in disguise. Bright red or maroon rectal bleeding unexpectedly originates from UGI sources about 14% of the time.3 Although most patients will volunteer complaints of hematemesis or melena, UGI bleeding may also be subtle. Patients with hypotension, tachycardia, angina, syncope, weakness, confusion, or cardiac arrest may have underlying GI hemorrhage.

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Ask about hematemesis, coffee-ground emesis, or melena. Classically, hematemesis and coffee-ground emesis suggests an UGI source. In patients without a history of hematemesis, the presence of melena and an age <50 years old suggest an UGI source.4 Vomiting ...

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