Upper gastrointestinal bleeding differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

The various causes responsible for UGIB include peptic ulcer disease, esophagitis, gastritis/gastropathy, esophagogastric varices, ectopic varices, portal hypertensive gastropathy, angiodysplasia, dieulafoy's lesion, gastric antral vascular ectasia, mallory-Weiss syndrome and upper GI tumors and must be differentiated from one another.

Differentiating Upper Gastrointestinal Bleeding from other Diseases

Several diseases can present with UGIB, and hence must be differentiated from one another.

The following table summarizes the various causes of Upper gastrointestinal bleeding

Disease/Cause	Bleeding manifestations				Associated signs and symptoms	Risk factors	Endoscopic findings
	Hematemesis	Melena	Hematochezia	Occult blood
Ulcerative or erosive
Peptic ulcer disease	+	+	+	+	Abdominal pain Pain associated with eating Dyspepsia	NSAIDs Infections: Helicobacter pylori CMV HSV Stress ulcer 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	+	+	-	+	Dysphagia Odynophagia Retrosternal pain	Gastroesophageal reflux disease Medications: Tetracycline Doxycycline Clindamycin Trimethoprim-sulfamethoxazole NSAIDs Oral bisphosphonates Potassium chloride Quinidine Iron supplements  Infections: HSV CMV Candida albicans HIV	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	+	+	-	+	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	+	+	+	-	Stigmata of chronic liver disease Signs of portal hypertension (splenomegaly, ascites, thrombocytopenia)	Portal hypertension from: Cirrhosis Portal vein thrombosis Non-cirrhotic 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
Ectopic varices	+	+	+	-	Stigmata of chronic liver disease Signs of portal hypertension (splenomegaly, ascites, thrombocytopenia)	Portal hypertension from: Cirrhosis Portal vein thrombosis Non-cirrhotic 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	+	+	+	+	Stigmata of chronic liver disease Signs of portal hypertension (splenomegaly, ascites, thrombocytopenia)	Portal hypertension from: Cirrhosis Portal vein thrombosis Non-cirrhotic portal hypertension	Mosaic-like pattern that gives the gastric mucosa a "snakeskin" appearance
Vascular lesions
Angiodysplasia	+	+	+	+	Cutaneous angiodysplasia (Osler-Weber-Rendu syndrome)	End-stage renal 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	+	+	+	-	Dyspepsia Dizziness, syncope, May have no prior history before bleed	Bleeding may be associated with NSAIDs use Cardiovascular disease, Hypertension, Chronic kidney disease, Diabetes Alcohol abuse	Usually located in the proximal stomach 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
Gastric antral vascular ectasia	+	+	+	+	Stigmata of chronic liver disease	Idiopathic Cirrhosis with portal hypertension Renal disease Diabetes mellitus Scleroderma Bone marrow transplantation	Longitudinal rows of flat, reddish stripes radiating from the pylorus into the antrum.
Traumatic or iatrogenic
Mallory-Weiss syndrome	+	+	+	-	Epigastric pain Back pain	Vomiting/retching (often related to alcohol consumption) Straining at stool or lifting Coughing Seizures Blunt abdominal trauma Hiatal hernia	Tear in the esophagogastric junction. Usually singular and longitudinal, but may be multiple. Visualization may require retro-flexion of the gastroscope in the cardia of the stomach. The tear may be covered by an adherent clot.
Foreign body ingestion	+	+	+	+	Dysphagia Odynophagia Neck or abdominal pain Choking Hypersalivation Retrosternal fullness	Psychiatric disorders Dementia Loose dentures	Visualization of the foreign body endoscopically.
Post-surgical anastomotic bleeding ("marginal ulcers")	+	+	+	+	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	+	+	+	-	Past history of instrumentation	Large lesions	Bleeding at resection site; ulceration at the site may be seen
Cameron lesions	+	+	+	+		Hiatal hernia Reflux esophagitis	Linear ulcers or erosions on the mucosal folds of a hiatal hernia at the diaphragmatic impression.
Aortoenteric fistula	+	+	+	-	Back pain Fever Signs of sepsis Pulsatile abdominal mass Abdominal bruit	Infectious aortitis Prosthetic aortic graft Atherosclerotic aortic aneurysm Penetrating ulcers Tumor invasion Trauma Radiation injury Foreign body perforation	Endoscopy 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	+	+	+	+	Weight loss Anorexia Nausea/vomiting Early satiety Epigastric pain Dysphagia (for tumors in the esophagus or proximal stomach) Gastric outlet obstruction Palpable mass Para-neoplastic manifestations: Diffuse seborrheic keratoses Acanthosis nigricans Membranous nephropathy Coagulopathy	Virtually any tumor type may bleed †	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 Polypoid lesion As a gastric ulcer
Miscellaneous
Hemobilia	+	+	+	-	Biliary colic Jaundice (obstructive) Sepsis (biliary)	Past history of: 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. ERCP may reveal a filling defect in the bile duct
Hemosuccus pancreaticus	+	+	+	-	Abdominal pain Past evidence of symptoms/signs of pancreatitis Imaging evidence of pancreatitis. Elevated amylase and lipase .	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. Cross-sectional imaging or angiography is often required to confirm the diagnosis.

References

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