Unusual Causes of Upper GI Bleed

Today we talked about UGIB with Dr. Ho Ping Kong. Here are some key points we talked about:

1) Most common causes of UGIB:

• Peptic Ulcer disease - 55%
• Variceal - 14%
• Arterial, venous and other vascular malformations - 11%
• Mallory Weiss - 5% (although Dr. HPK would disagree)
• Erosions - 4%
• Malignancy - 4$
• Other - 11%

2) Unusual causes of UGIB:

Watermelon Stomach

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• Dieulafoy's lesion: Dilated submucosal vessel that is usually located in the antrum of the stomach, but can be found in the esophagus and duodenum. Thought to be congenital. As the artery is not surrounded by stomach muscle, it can become dilated. The artery can bleed (triggered by NSAIDs?) resulting in profuse bleeding, that is often self limited.
• Gastric Antral Vascular Ectasia (GAVE): AKA Watermelon stomach. Characterized by longitudinal rows of ectatic/sacculated mucosal vessels running from the antrum to the pylorus. Can be idiopathic, but also associated with cirrhosis and systemic sclerosis. Most common presentation is that of slow, chronic blood loss and iron deficiency anemia. 
• Vascular anomalies: Osler-Weber-Rendu or Hereditary Hemorrhagic Telangiectasia, Ehrlos Danlos, CREST, Klippel-Trenaunay-Weber syndrome.
• Portal Hypertensive Gastropathy: Occurs in patients with cirrhosis and portal hypertension. Mucosa has a snakeskin like appearance with a fine white reticular pattern and areas of pink mucosa.
• Hemobilia: Bleeding from the hepatobiliary tract. Usually occuring after hepatobiliary instrumentation.
• Hemosuccus Pancreaticus: Bleeding from the pacreatic duct. Usually occurs with pancreatic pseudocysts or tumours that erode into adjacent arteries.
• Aortoenteric Fistulas: Usually secondary to ulcers/tumours. Arteries affected include aorta, gastroduodenal artery.
• Cameron lesions: Ulcers in a hiatus hernia
• Tumours: Lymphoma, Kaposi's sarcoma
• Secondary Angiodysplasia: End stage renal disease, aortic stenosis and Heyde's syndrome

3) Unusual causes of PUD:

• H. Pylori (~61% of DU and ~63% GU) and NSAIDs account for the majority of peptic ulcer disease.
• Gastrinoma: Zollinger-Ellison Syndrome: Non-beta cell islet tumour of the pancreas associated with acid hypersecretion and multiple peptic ulcers. Can occur sporadically or in association with MEN I (hyperparathyroidism, pancreatic tumours and anterior pituitary tumors).
• Systemic mastocytosis: Secondary to increased circulating histamine
• Carcinoid tumours: Also secondary to increased circulating histamine
• Other infections: HSV-1, CMV
• Stress ulceration: Hospitalized/critically ill ICU patients
• Sarcoidosis
• Crohn's Disease

4) HPK Classic (Couldn't leave this out)

Bob Marley leads to Rastafari leads to Rasmussen's Aneurysm 

Rasmussen's Aneurysm: A pulmonary artery aneurysm adjacent to or within a tuberculous cavity. Can cause fatal hemoptysis

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