Upper gastrointestinal bleeding differential diagnosis

Jump to: navigation, search
Home logo1.png

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.[1][2][3][4][5][6][7]

The following table summarizes the various causes of Upper gastrointestinal bleeding

Disease/Cause Bleeding manifestations Symptoms Risk factors Endoscopic findings
Hematemesis Melena Hematochezia Occult blood Abdominal
pain
Dysphagia Dyspepsia Weighloss
Ulcerative or erosive
Peptic ulcer disease + + + + + - + +/-
  • Ulcer with smooth, regular, rounded edges
  • Ulcer base often filled with exudate
  • Examination of the ulcer may reveal:
    • Active bleeding
    • Nonbleeding visible vessel
    • Adherent clot
    • Flat pigmented spot
    • Clean ulcer base
Esophagitis + + - + - + - -
  • Peptic esophagitis
    • The ulcerations are usually irregularly shaped or linear, multiple, and distal.
  • Pill-induced
  • 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 + + - + + - + -
  • Erythematous mucosa
  • Superficial erosions
  • Nodularity
  • Diffuse oozing
Complications of portal hypertension
Esophagogastric varices + + + - + - - -
  • 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 + + + - - - - -
Portal hypertensive gastropathy + + + + + - - -
  • Mosaic-like pattern that gives the gastric mucosa a "snakeskin" appearance
Vascular lesions
Angiodysplasia + + + + - - - -
  • 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 + + + - + - - -
  • 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 + + + + + - - -
  • Longitudinal rows of flat, reddish stripes radiating from the pylorus into the antrum.
Traumatic or iatrogenic
Mallory-Weiss syndrome + + + - - - - -
  • Tear in the esophagogastric junction.
  • Usually singular and longitudinal, but may be multiple.
  • The tear may be covered by an adherent clot.
Foreign body ingestion + + + + - + - -
  • Psychiatric disorders
  • Dementia
  • Loose dentures
  • Visualization of the foreign body endoscopically.
Post-surgical anastomotic hemorrhage (marginal ulcers) + + + + + - + -
  • Ulceration/friable mucosa at an anastomotic site.
Aortoenteric fistula + + + - + - - -
  • 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
  • Adherent clot, or an extrinsic pulsatile mass in the distal duodenum or esophagus.
Tumors
Upper GI 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
Miscellaneous
Hemobilia + + + - + - - - History of:
Hemosuccus pancreaticus + + + - + - + -
  • Blood or clot emanating from the ampulla.
  • Cross-sectional imaging or angiography is often required to confirm the diagnosis.

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Peptic ulcer disease Diffuse ± + + Positive if perforated Positive if perforated Positive if perforated N
  • Ascitic fluid
    • LDH > serum LDH
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
Gastritis Epigastric ± + Positive in chronic gastritis + N
Gastrointestinal perforation Diffuse + ± - ± + + + ± Hyperactive/hypoactive
  • WBC> 10,000
Budd-Chiari syndrome RUQ ± ± Positive in liver failure leading to varices N
Findings on CT scan suggestive of Budd-Chiari syndrome include:
Ascitic fluid examination shows:
Cirrhosis RUQ + + + + N US
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur
Hemochromatosis RUQ Positive in cirrhotic patients N
  • >60% TS
  • >240 μg/L SF
  • Raised LFT
    Hyperglycemia
  • Ultrasound shows evidence of cirrhosis
Extra intestinal findings:
  • Hyperpigmentation
  • Diabetes mellitus
  • Arthralgia
  • Impotence in males
  • Cardiomyopathy
  • Atherosclerosis
  • Hypopituitarism
  • Hypothyroidism
  • Extrahepatic cancer
  • Prone to specific infections
Inflammatory bowel disease Diffuse ± ± + + + Normal or hyperactive

Extra intestinal findings:

Ruptured abdominal aortic aneurysm Diffuse ± + + + + N
  • Focused Assessment with Sonography in Trauma (FAST) 
  • Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage Diffuse ± ± + + N
  • ↓ Hb
  • ↓ Hct
  • CT scan

References

  1. Graham DY (2016). "Upper Gastrointestinal Bleeding Due to a Peptic Ulcer". N. Engl. J. Med. 375 (12): 1197–8. doi:10.1056/NEJMc1609017#SA2. PMID 27653583.
  2. Chen ZJ, Freeman ML (2011). "Management of upper gastrointestinal bleeding emergencies: evidence-based medicine and practical considerations". World J Emerg Med. 2 (1): 5–12. PMC 4129733. PMID 25214975.
  3. Kaufman DW, Kelly JP, Wiholm BE, Laszlo A, Sheehan JE, Koff RS, Shapiro S (1999). "The risk of acute major upper gastrointestinal bleeding among users of aspirin and ibuprofen at various levels of alcohol consumption". Am. J. Gastroenterol. 94 (11): 3189–96. doi:10.1111/j.1572-0241.1999.01517.x. PMID 10566713.
  4. Lee EW, Laberge JM (2004). "Differential diagnosis of gastrointestinal bleeding". Tech Vasc Interv Radiol. 7 (3): 112–22. PMID 16015555.
  5. Lee YT, Walmsley RS, Leong RW, Sung JJ (2003). "Dieulafoy's lesion". Gastrointest. Endosc. 58 (2): 236–43. doi:10.1067/mge.2003.328. PMID 12872092.
  6. Ghosh S, Watts D, Kinnear M (2002). "Management of gastrointestinal haemorrhage". Postgrad Med J. 78 (915): 4–14. PMC 1742226. PMID 11796865.
  7. Chalasani N, Clark WS, Wilcox CM (1997). "Blood urea nitrogen to creatinine concentration in gastrointestinal bleeding: a reappraisal". Am. J. Gastroenterol. 92 (10): 1796–9. PMID 9382039.



Linked-in.jpg