History points for upper GI Bleed patient
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History Points in a Patient with Upper GI Bleed
1. Presenting Complaint - Nature of Bleeding
- Hematemesis - bright red blood or "coffee-ground" vomiting (digested blood)
- Melena - black, tarry, foul-smelling stools (blood from proximal to ligament of Treitz)
- Hematochezia - fresh red blood PR; seen in ~10-15% of UGIB and implies a brisk, massive bleed
- Onset, duration, volume/quantity of blood lost, number of episodes
2. Associated Symptoms (Clues to Severity & Cause)
| Symptom | Implication |
|---|---|
| Dizziness, syncope, postural symptoms | Hypovolaemia / significant blood loss |
| Epigastric pain before bleeding | Peptic ulcer disease |
| Heartburn, dysphagia | Erosive esophagitis, Barrett's |
| Nausea/vomiting preceding bleeding | Mallory-Weiss tear |
| Weight loss, anorexia, dysphagia | GI malignancy |
| Abdominal pain + jaundice | Haemobilia, cholangitis |
3. Drug & Substance History
- NSAIDs / Aspirin (including OTC) - strongly associated with peptic ulcer bleeding
- Anticoagulants - warfarin, DOACs (risk stratification; INR ≥1.5 predicts increased mortality)
- Antiplatelets - clopidogrel, ticagrelor
- Corticosteroids - increase ulcer risk especially with NSAIDs
- Herbal supplements - some contain salicylates
- Alcohol - heavy intake suggests Mallory-Weiss tear or alcoholic gastritis/varices
- Iron / bismuth - can mimic melena (black stools without bleeding)
4. Past Medical History
- Peptic ulcer disease - most common cause (~38-40% of UGIB)
- Liver disease / cirrhosis - portal hypertension raises suspicion for varices or portal hypertensive gastropathy
- GERD - erosive esophagitis
- Previous GI surgery - surgical anastomosis, aortic graft (aortoenteric fistula)
- Coagulopathy / haematological disorders - thrombocytopenia, haemophilia
- Renal failure - platelet dysfunction, uraemia
- Cardiovascular disease - affects transfusion targets
- History of previous GI bleed - prior episodes, previous endoscopy/treatment
5. Family History
- GI malignancy
- Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu)
- Inflammatory bowel disease
6. Feeding Tubes / Instrumentation
- Chronic nasogastric tube - raises suspicion for erosive esophagitis
- Recent endoscopy, instrumentation, or surgery (iatrogenic causes)
7. History Clues for Specific Diagnoses
| History Finding | Likely Cause |
|---|---|
| Daily NSAID/aspirin use | Peptic ulcer (gastric or duodenal) |
| Known cirrhosis, jaundice, ascites | Oesophageal/gastric varices, portal hypertensive gastropathy |
| Heavy alcohol use + retching/vomiting | Mallory-Weiss tear |
| GERD + feeding tube | Severe erosive esophagitis |
| Prior aortic graft surgery | Aortoenteric fistula |
| History of pancreatitis + isolated gastric varices | Splenic vein thrombosis (SVT) |
| Radiation therapy to abdomen | Radiation gastritis/telangiectasia |
| Hereditary bleeding disorders | Angiodysplasia, Dieulafoy lesion, HHT |
8. Social History
- Alcohol intake (quantity, duration, type)
- Smoking (increases peptic ulcer risk)
- NSAID/analgesic self-medication (often under-reported)
- Travel history (infectious causes, though less common)
9. Review of Systems / Functional Enquiry
- Signs of chronic liver disease: jaundice, easy bruising, peripheral oedema
- Weight loss, night sweats (malignancy)
- Dysphagia (tumour, stricture)
- Recent vomiting/retching prior to haematemesis (Mallory-Weiss)
Key pearl from Goldman-Cecil Medicine: "Patients should be asked questions that can help determine the diagnostic possibilities for the bleeding source. Peptic ulcer bleeding should be suspected in patients taking daily aspirin or NSAIDs. For patients with known or suspected liver disease, bleeding related to portal hypertension should be strongly considered. Heavy alcohol intake or vomiting should suggest a Mallory-Weiss tear. A feeding tube or chronic NGT and a history of GORD raise suspicion for severe erosive esophagitis." - Goldman-Cecil Medicine, p. 1397
Sources: Goldman-Cecil Medicine (26th ed.) | Yamada's Textbook of Gastroenterology (7th ed.) | Harrison's Principles of Internal Medicine (22nd ed.)
Generate a quick reference guide comparing differential diagnoses by history
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Here is your quick reference guide:
Upper GI Bleed - Differential Diagnosis by History
At a Glance
| # | Diagnosis | Frequency |
|---|---|---|
| 1 | Peptic ulcer disease (gastric/duodenal) | ~40-50% |
| 2 | Oesophageal/gastric varices | ~16% |
| 3 | Erosive esophagitis / gastritis | ~13% |
| 4 | GI neoplasm | ~7% |
| 5 | Angiodysplasia / vascular lesions | ~6% |
| 6 | Mallory-Weiss tear | ~4% |
| 7 | Dieulafoy lesion | ~2% |
| 8 | Other (aortoenteric fistula, haemobilia, Cameron ulcer) | ~2% |
Differential Diagnosis by History - Comparison Table
| Diagnosis | Typical Patient Profile | Key History Clues | Type of Bleed | Red Flag Pointers |
|---|---|---|---|---|
| Peptic Ulcer Disease | Middle-aged to elderly, M > F | Chronic epigastric pain (often relieved by food or antacids); daily NSAID/aspirin use (including OTC); smoking; H. pylori risk; corticosteroid use | Hematemesis and/or melena; may be painless when on NSAIDs | Prior ulcer or UGIB (60% of recurrent bleeds = same lesion); nocturnal pain waking patient |
| Oesophageal/Gastric Varices | Any age; cirrhotic or chronic liver disease patients | Known cirrhosis, hepatitis B/C, heavy alcohol use; prior variceal bleed (60% re-bleed within 12 months); jaundice, ascites, easy bruising | Sudden, massive hematemesis; often bright red, large volume | 20% mortality per bleed episode; haemodynamic instability; stigmata of chronic liver disease |
| Erosive Esophagitis | Adults with GERD; critically ill patients | Longstanding heartburn / regurgitation; chronic NGT or feeding tube; immunosuppression; anticoagulant use; critically ill/ICU (stress ulceration) | Hematemesis or melena; usually lower volume | Risk factors: cirrhosis (moderate-severe), poor performance status, anticoagulation |
| Erosive Gastritis / Duodenitis | NSAID users; alcohol users; critically ill | Heavy NSAID/aspirin use; heavy alcohol intake; physiological stress (burns, head injury, sepsis); no prodromal epigastric pain (often silent) | Hematemesis (coffee-ground) or melena | May be diffuse, difficult to control endoscopically |
| Mallory-Weiss Tear | Young to middle-aged; alcohol users | Forceful retching/vomiting or coughing immediately before hematemesis; alcohol binge; eating disorder (bulimia); pregnancy (hyperemesis gravidarum) | Hematemesis after forceful vomiting - blood appears after non-bloody vomit initially | Severe bleeding if portal hypertension co-exists; mostly self-limiting (~95%) |
| GI Neoplasm (gastric/oesophageal cancer) | Older adults (>50 years); M > F | Progressive dysphagia; anorexia; unintentional weight loss; early satiety; change in bowel habit; family history of GI cancer | Hematemesis or melena; often slow/insidious; may present as iron-deficiency anaemia | Age >50 with new dyspepsia; dysphagia is an alarm symptom; any palpable abdominal mass |
| Dieulafoy Lesion | Middle-aged to elderly; male predominance | No preceding epigastric symptoms; often no precipitating history; hypertension, cardiovascular disease, renal failure, diabetes; alcohol use | Sudden, massive, intermittent hematemesis without abdominal pain; "herald bleeds" | Recurrent massive bleeds with no identifiable cause on initial endoscopy |
| Angiodysplasia / GAVE | Elderly (>60 years); systemic disease | History of aortic stenosis (Heyde's syndrome), chronic renal failure, hereditary haemorrhagic telangiectasia (HHT/Osler-Weber-Rendu), liver cirrhosis (GAVE) | Chronic occult bleeding or intermittent overt bleeds; melena or iron-deficiency anaemia | Elderly patient with unexplained anaemia; known connective tissue disease |
| Aortoenteric Fistula | Elderly; post-vascular surgery | Previous aortic graft surgery (typically 5+ years ago); pulsatile abdominal mass; "herald bleed" (small initial bleed, then catastrophic haemorrhage) | Massive hematemesis or melena; often preceded by a small sentinel bleed | Prior aortic graft = must exclude AEF; extremely high mortality if missed |
| Haemobilia | Post-procedural / trauma | Recent hepatobiliary surgery, liver biopsy, ERCP, or trauma; RUQ pain + jaundice (Quincke's triad) | Hematemesis or melena; blood in biliary tree | Classic triad: upper GI bleed + RUQ pain + jaundice = haemobilia until proven otherwise |
Quick "Pattern Recognition" Summary
| If you hear this... | Think this |
|---|---|
| "NSAID/aspirin for months, epigastric pain" | Peptic ulcer disease |
| "Cirrhosis, jaundice, known varices, sudden massive bleed" | Oesophageal/gastric varices |
| "Retching/vomiting, then blood appeared" | Mallory-Weiss tear |
| "Heartburn for years, NGT in place" | Erosive esophagitis |
| "Weight loss, dysphagia, >50 years old" | GI malignancy |
| "Recurrent massive bleeds, no cause found" | Dieulafoy lesion |
| "Elderly, aortic stenosis, iron-deficiency anaemia" | Angiodysplasia |
| "Previous aortic graft, small initial bleed" | Aortoenteric fistula |
| "Post-liver biopsy, RUQ pain + jaundice + bleed" | Haemobilia |
| "Alcohol binge, no prior GI disease" | Alcoholic gastritis / Mallory-Weiss |
| "ICU patient, burns, head injury, sepsis" | Stress ulceration / erosive gastritis |
Sources: Goldman-Cecil Medicine (26th ed.) | Fischer's Mastery of Surgery (8th ed.) | Yamada's Textbook of Gastroenterology (7th ed.) | Harrison's Principles of Internal Medicine (22nd ed.)
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