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Disorders that cause upper GI bleeding in adults

Cause	Bleeding manifestations	Associated signs and symptoms	Associated conditions or risk factors	Endoscopic findings*
Ulcerative or erosive
Duodenal and/or gastric ulcer	Hematemesis Melena Hematochezia (indicates brisk bleeding) Occult blood loss	Upper abdominal pain Pain associated with eating (worse when eating suggests gastric ulcer, improvement with eating suggests duodenal ulcer) Dyspepsia^¶	Infections: Helicobacter pylori CMV HSV NSAIDs Stress ulcer (eg, in patients who are critically ill) Excess gastric acid production (ZES) Idiopathic	Ulcer with smooth, regular, rounded edges; ulcer base often filled with exudate Examination of the ulcer may reveal: Active bleeding or oozing Nonbleeding visible vessel Adherent clot Flat pigmented spot Clean ulcer base
Esophagitis	Hematemesis Melena Occult blood loss	Dysphagia/odynophagia Retrosternal pain Food impaction	Gastroesophageal reflux disease Medications that may cause "pill esophagitis": Erythromycin Tetracycline Doxycycline Clindamycin Trimethoprim-sulfamethoxazole NSAIDs Oral bisphosphonates Potassium chloride Quinidine Iron supplements Infections: HSV CMV Candida albicans HIV	Erythema, mucosal breaks/erosions, exudative lesions, superficial or deep ulcers, stenosis, scarring Peptic esophagitis: The ulcerations are usually irregularly shaped or linear, multiple, and distal; may be accompanied by Barrett's esophagus Pill-induced: Ulcerations are usually singular and deep, occurring at points of stasis (especially near the carina), with sparing of the distal esophagus Infectious esophagitis: HSV – Discrete, superficial ulcers, with well-demarcated borders that tend to involve the upper or mid-esophagus; vesicles may be seen CMV – Ulcers range from small and shallow to large (>1 cm) and deep; most patients have multiple lesions Candida – Diffuse white plaques HIV – Tends to involve the mid to distal esophagus, ulcers may be shallow or deep, and may be large
Gastritis/gastropathy Duodenitis/duodenopathy	Occult blood loss Hematemesis Melena	Dyspepsia^¶	Risk factors: H. pylori NSAIDs Excessive alcohol consumption Radiation injury Physiologic stress Weight loss surgery Bile reflux Risk factors for bleeding: Anticoagulant use	Erythematous mucosa Superficial erosions Nodularity Diffuse oozing
Complications of portal hypertension
Esophagogastric varices	Hematemesis Melena Hematochezia (indicates brisk bleeding)	Stigmata of chronic liver disease^Δ, in particular, signs of portal hypertension (splenomegaly, ascites, thrombocytopenia)	Portal hypertension from: Cirrhosis Portal vein thrombosis Noncirrhotic portal hypertension	Vascular structures that protrude into the esophageal and/or gastric lumen Findings associated with an increased risk of hemorrhage: Longitudinal red streaks on the varices (red wale marks) Cherry-colored spots that are flat and overlie varices Raised, discrete red spots (hematocystic spots) Esophageal varices: F1: Small, straight varices F2: Enlarged, tortuous varices that occupy less than one-third of the lumen F3: Large, coil-shaped varices that occupy more than one-third of the lumen Gastric varices: GOV1: Gastroesophageal varices along the lesser curvature of the stomach GOV2: Gastroesophageal varices along the greater curvature of the stomach IGV1: Isolated gastric varices in the fundus IGV2: Isolated gastric varices at other loci in the stomach
Ectopic varices	Hematemesis Melena Hematochezia (indicates brisk bleeding)	Stigmata of chronic liver disease^Δ, in particular, signs of portal hypertension (splenomegaly, ascites, thrombocytopenia)	Portal hypertension from: Cirrhosis Portal vein thrombosis Noncirrhotic portal hypertension	Vascular structures that protrude into areas of the gastrointestinal tract lumen other than the esophagus or stomach (eg, small bowel, rectum)
Portal hypertensive gastropathy	Occult blood loss Hematemesis Melena Hematochezia (indicates brisk bleeding)	Stigmata of chronic liver disease^Δ, in particular, signs of portal hypertension (splenomegaly, ascites, thrombocytopenia)	Portal hypertension from: Cirrhosis Portal vein thrombosis Noncirrhotic portal hypertension	Mosaic-like pattern that gives the gastric mucosa a "snakeskin" appearance Mucosal changes are usually most evident in the fundus and body; in more severe cases, oozing, bleeding, subepithelial hemorrhages, and increased vascularity similar to angiomas are evident, often involving the gastric fundus, gastric body, and antrum
Vascular lesions
Angiodysplasia	Hematemesis Melena Hematochezia Occult blood loss May have brisk bleeding	Cutaneous angiodysplasia in patients with hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)	End-stage kidney disease Aortic stenosis Left ventricular assist device Hereditary hemorrhagic telangiectasia von Willebrand disease Radiation therapy Idiopathic	Small (5 to 10 mm), flat, cherry-red lesions, often with a fern-like pattern of arborizing, ectatic blood vessels radiating from a central vessel
Dieulafoy's lesion	Hematemesis Melena Hematochezia (indicates brisk bleeding; bleeding is often particularly brisk)		Etiology unknown Bleeding may be associated with NSAIDs, cardiovascular disease, hypertension, chronic kidney disease, diabetes, or alcohol abuse	Usually located in the proximal stomach (within 6 cm of the esophagogastric junction) along the lesser curvature (although can be found anywhere in the GI tract) May have active arterial spurting from the mucosa without an associated ulcer or mass If the bleeding has stopped, there may be a raised nipple or visible vessel without an associated ulcer Endoscopic ultrasound may help confirm the diagnosis
Gastric antral vascular ectasia (GAVE)	Hematemesis Melena Hematochezia (indicates brisk bleeding) Occult blood loss	In patients with cirrhosis, there may be stigmata of chronic liver disease^Δ, in particular, signs of portal hypertension (splenomegaly, ascites, thrombocytopenia)	Idiopathic Cirrhosis with portal hypertension Kidney disease/transplantation Diabetes mellitus Systemic sclerosis (scleroderma) Bone marrow transplantation	Longitudinal rows of flat, reddish stripes radiating from the pylorus into the antrum that resemble the stripes on a watermelon
Blue rubber bleb nevus syndrome (Bean syndrome)	Hematemesis Melena Hematochezia (indicates brisk bleeding) Occult blood loss	Venous malformations and hemangiomas of any organ, including: Skin Central nervous system Liver Muscles Lymphatics Intussusception		Blue or purple nodules, round or multilobular; may occur anywhere in the gastrointestinal tract
Traumatic or iatrogenic
Mallory-Weiss syndrome	Hematemesis following an increase in intra-abdominal pressure Melena Hematochezia (indicates brisk bleeding)	Epigastric pain Back pain	Vomiting/retching (often related to alcohol consumption) Straining at stool or lifting Coughing Seizures Blunt abdominal trauma Hiatal hernia may increase the risk of developing a tear	Tear in the esophagogastric junction Usually singular and longitudinal, but may be multiple Visualization may require retroflexion of the gastroscope in the cardia of the stomach The tear may be covered by an adherent clot
Foreign body ingestion	Hematemesis Melena Hematochezia (indicates brisk bleeding) Occult blood loss	Dysphagia Odynophagia Neck or abdominal pain Choking Hypersalivation Retrosternal fullness	Psychiatric disorders Altered mental status (toxin induced, dementia, etc) Loose dentures	Visualization of the foreign body endoscopically (plain radiographs of the neck, chest, and abdomen may reveal a radiopaque foreign body or signs of perforation)
Post-surgical anastomotic bleeding ("marginal ulcers")	Occult blood loss Hematemesis Melena Hematochezia (indicates brisk bleeding)	Epigastric pain Nausea	Billroth II surgery Gastric bypass surgery NSAID use H. pylori infection Smoking	Ulceration/friable mucosa at an anastomotic site
Post-polypectomy/endoscopic resection/endoscopic sphincterotomy	Hematemesis Melena Hematochezia (indicates brisk bleeding)	Past history of instrumentation (may be as long as three weeks prior to presentation)	Large lesions	Bleeding at resection site; ulceration at the site may be seen
Cameron lesions	Occult blood loss Hematemesis Melena Hematochezia (indicates brisk bleeding)		Hiatal hernia Reflux esophagitis	Linear ulcers or erosions on the mucosal folds of a hiatal hernia at the diaphragmatic impression
Aortoenteric fistula	Hematemesis Melena Hematochezia (indicates brisk bleeding) May have a "herald" bleed followed by massive bleeding	Back pain Fever Signs of sepsis Pulsatile abdominal mass Abdominal bruit	Infectious aortitis (syphilis, tuberculosis) Prosthetic aortic graft Atherosclerotic aortic aneurysm Penetrating ulcers Tumor invasion Trauma Radiation injury Foreign body perforation	Endoscopy is important, primarily to exclude other, more common causes of acute upper GI bleeding Endoscopy with an enteroscope or side-viewing duodenoscope may reveal a graft, an ulcer or erosion at the site of an adherent clot, or an extrinsic pulsatile mass in the distal duodenum or esophagus
Tumors
Upper GI tumors	Hematemesis Melena Hematochezia (indicates brisk bleeding) Occult blood loss	Weight loss Anorexia Nausea/vomiting Early satiety Epigastric pain Dysphagia (for tumors in the esophagus or proximal stomach) Gastric outlet obstruction Palpable mass Paraneoplastic manifestations: Diffuse seborrheic keratoses Acanthosis nigricans Membranous nephropathy Coagulopathy	Virtually any tumor type may bleed Benign tumors: Leiomyoma Lipoma Polyp (hyperplastic, adenomatous, hamartomatous, inflammatory) Malignant tumors: Adenocarcinoma GI stromal tumors Lymphoma Kaposi sarcoma Carcinoid Melanoma Metastatic tumors	Ulcerated mass in the esophagus, stomach, or duodenum In gastric malignancies, the folds surrounding the ulcer crater may be nodular, clubbed, fused, or stop short of the ulcer margin; the margins may be overhanging, irregular, or thickened Bleeding lymphoma may appear as an ulcerated mass or polypoid lesion or as a gastric ulcer
Miscellaneous
Hemobilia	Hematemesis Melena Hematochezia (indicates brisk bleeding)	Biliary colic Jaundice (obstructive) Sepsis (biliary)	Past history of liver or biliary tract instrumentation and/or injury, including the following: Liver biopsy Cholecystectomy Endoscopic biliary biopsies or stenting TIPS placement Angioembolization Blunt or penetrating abdominal trauma Gallstones Cholecystitis Hepatic or bile duct tumors Intrahepatic stents Hepatic artery aneurysms Hepatic abscesses	Blood or clot emanating from the ampulla (a side-viewing duodenoscope may be required to visualize the ampulla) If a clot has formed in the bile duct, bleeding may not be appreciated until the clot is removed ERCP may reveal a filling defect in the bile duct
Hemosuccus pancreaticus	Hematemesis Melena Hematochezia (indicates brisk bleeding)	Abdominal pain Past evidence of symptoms/signs of pancreatitis Imaging evidence of pancreatitis (current or in the past) Elevated amylase and lipase (current or in the past)	Chronic pancreatitis Pancreatic pseudocysts Pancreatic tumors Pancreatic pseudoaneurysm Therapeutic endoscopy of the pancreas or pancreatic duct: Pancreatic stone removal Pancreatic duct sphincterotomy Pseudocyst drainage Pancreatic duct stenting	Blood or clot emanating from the ampulla (a side-viewing duodenoscope may be required to visualize the ampulla) Cross-sectional imaging or angiography is often required to confirm the diagnosis

CMV: cytomegalovirus; HSV: herpes simplex virus; ZES: Zollinger-Ellison syndrome; NSAID: nonsteroidal anti-inflammatory drug; HIV: human immunodeficiency virus; GI: gastrointestinal; TIPS: transjugular intrahepatic portosystemic shunt; ERCP: endoscopic retrograde cholangiopancreatography.
* If active bleeding or large amounts of residual blood are present, the characteristic endoscopic findings may be obscured.
¶ Postprandial fullness, early satiety, epigastric pain, or burning.
Δ Evidence of chronic liver disease includes jaundice, splenomegaly, ascites, thrombocytopenia, palmar erythema, spider angiomata, gynecomastia, testicular atrophy, and Dupuytren's contracture.

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