Upper Gastrointestinal Bleeding (UGIB) Differential Diagnoses

Updated: Sep 01, 2021
  • Author: Bennie Ray Upchurch, III, MD, FACP, AGAF, FACG, FASGE; Chief Editor: BS Anand, MD  more...
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Diagnostic Considerations

Acute upper gastrointestinal (GI) bleeding (UGIB) may originate from pathology in the esophagus, stomach, or duodenum.

The most common causes of acute UGIB are peptic ulcer disease (including from the use of aspirin and other nonsteroidal anti-inflammatory drugs [NSAIDs]), H pylori infection, variceal hemorrhage, Mallory-Weiss tears, gastric and duodenal erosions, and neoplasms (including gastric cancers). Additional common etiologies include esophagitis, vascular ectasias, and Dieulafoy lesions.

UGIB can be categorized on the basis of the following anatomic and pathophysiologic factors: ulcerative, vascular, traumatic, iatrogenic, tumors, and portal hypertension. [37] Certain risk factors or comorbidities, such as the following, may help refine the differential diagnosis [38] :

  • A previous history of acid-peptic disease or UGIB
  • Underlying cardiovascular or cerebrovascular disease (eg, valvular heart disease) or taking antithrombotic agents
  • Known advanced liver disease, with possible underlying cirrhosis
  • Severe systemic illness ,with possible disseminated intravascular coagulation
  • Having known bleeding dyscrasias, chronic kidney disease, or von Willebrand disease, which may predispose to vascular ectasias

In individuals known to have an abdominal aortic aneurysm or an aortic graft, clinicians should strongly consider acute GI bleeding secondary to an aortoenteric fistula. [39]

Individuals who have had previous upper GI surgery, such as Roux-en-Y gastric bypass or a Whipple procedure, are at risk for bleeding due to anastomotic or marginal ulceration; these patients should receive special consideration due to anatomic challenges to diagnosis and management.

Ulcer disease related to the Zollinger-Ellison syndrome, in which there is over-secretion of gastrin due to a gastrinoma, very rarely causes UGIB, with an annual incidence of 0.5 to 2 per million population. [40]

In addition to the disorders listed in the Differentials section below, diagnostic consideration should be given to the following conditions in patients with symptoms of UGIB:

  • Esophageal or gastric varices
  • Mallory-Weiss tear
  • Malignant neoplasm
  • Stress-related mucosal disease/stress ulcer
  • Dieulafoy lesion
  • Hemobilia
  • Pancreatic pseudoaneurysm
  • Aortoenteric fistula
  • Benign gastric tumors
  • Portal hypertensive gastropathy
  • Disseminated intravascular coagulation
  • Syncope
  • von Willebrand disease
  • Zollinger-Ellison syndrome

Differential Diagnoses