European Journal of Cardiovascular Medicine

Upper gastrointestinal bleeding (UGIB) is a major gastrointestinal emergency and remains an important cause of hospitalization, morbidity, resource utilization, and mortality worldwide. It is conventionally defined as bleeding arising proximal to the ligament of Treitz and therefore includes hemorrhage originating from the esophagus, stomach, and duodenum. Patients may present with hematemesis, coffee-ground vomiting, melena, or, in cases of brisk hemorrhage, hematochezia accompanied by hemodynamic instability. Despite substantial improvements in resuscitation, pharmacotherapy, therapeutic endoscopy, interventional radiology, and intensive care, UGIB continues to be associated with clinically important mortality, particularly among elderly patients and those with significant comorbid illnesses [1,2].

The etiological spectrum of UGIB is heterogeneous and varies considerably according to geographical region, age distribution, alcohol consumption, prevalence of chronic liver disease, Helicobacter pylori infection, medication exposure, and underlying comorbidities. Peptic ulcer disease has traditionally represented one of the most important causes of non-variceal UGIB. Other non-variceal etiologies include erosive gastritis and duodenitis, esophagitis, Mallory-Weiss tears, vascular lesions, and upper gastrointestinal malignancies [2,3]. In contrast, variceal hemorrhage represents a particularly important cause of UGIB in regions with a substantial burden of chronic liver disease and portal hypertension. Indian tertiary-care studies have demonstrated a considerable contribution of portal hypertension-related lesions, including esophageal and gastric varices, to the overall burden of UGIB [4].

Several modifiable and non-modifiable factors predispose individuals to upper gastrointestinal hemorrhage. Non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelet agents are among the most clinically relevant medication-related risk factors because of their adverse effects on gastroduodenal mucosal defense and hemostasis [5]. Anticoagulant therapy may further increase the likelihood or severity of gastrointestinal hemorrhage, particularly in older individuals and patients with multiple comorbidities. Alcohol consumption contributes through several pathways, including mucosal injury, chronic liver disease, portal hypertension, and coagulopathy. Chronic liver disease itself is particularly important because variceal bleeding can be severe, recurrent, and associated with substantial mortality [6].

The clinical severity of UGIB ranges from self-limiting mucosal bleeding to massive hemorrhage resulting in hypovolemic shock and death. Initial assessment therefore focuses not only on establishing the probable source of bleeding but also on identifying patients at increased risk of transfusion, therapeutic intervention, rebleeding, prolonged hospitalization, or mortality. Clinical parameters such as tachycardia, hypotension, syncope, altered sensorium, and evidence of poor peripheral perfusion may indicate significant blood loss. Laboratory parameters including hemoglobin, platelet count, blood urea nitrogen, creatinine, international normalized ratio, and liver-function parameters can provide additional information regarding severity and associated disease [7].

Risk-stratification systems have consequently become integral to contemporary UGIB management. The Glasgow-Blatchford Score is particularly useful during initial assessment because it incorporates clinical and laboratory variables to predict the requirement for intervention or adverse outcomes. Patients with very low scores can potentially be managed without hospitalization, whereas high-risk individuals require close monitoring and early intervention [8]. Current evidence-based recommendations emphasize prompt hemodynamic assessment, appropriate resuscitation, restrictive red-cell transfusion in most patients, risk stratification, and upper gastrointestinal endoscopy generally within 24 hours following presentation and stabilization [9]. The 2021 American College of Gastroenterology guideline, for example, supports the identification of very-low-risk patients using a Glasgow-Blatchford Score of 0–1 and recommends endoscopy within 24 hours for hospitalized patients with UGIB.

Upper gastrointestinal endoscopy remains fundamental for determining the source of bleeding, assessing high-risk stigmata, and providing endoscopic hemostasis when indicated. Importantly, the relative distribution of etiologies observed in Western populations cannot necessarily be extrapolated directly to Indian tertiary-care settings. Indian studies have reported a substantial burden of portal hypertension-related bleeding, while peptic ulcer disease, erosive mucosal disease, and other non-variceal lesions remain important contributors. Identification of the local clinical profile and associated risk factors is therefore essential for improving triage, directing early endoscopic intervention, and optimizing preventive strategies.

The present study was undertaken to evaluate the clinical profile, etiological spectrum, endoscopic findings, and major risk factors associated with upper gastrointestinal bleeding among patients presenting to a tertiary care hospital. It also aimed to determine the relationship of important clinical and demographic factors with the severity and outcomes of UGIB.

AIM AND OBJECTIVES

Aim: To evaluate the clinical profile and risk factors of upper gastrointestinal bleeding among patients presenting to a tertiary care hospital.

Objectives: To describe the demographic and clinical presentation of patients with UGIB; identify major behavioral, medication-related, and comorbid risk factors; determine the etiological and endoscopic spectrum of UGIB; and evaluate factors associated with severe bleeding and adverse in-hospital outcomes

Study design and setting

This hospital-based observational study was conducted in the Department of General Medicine/Gastroenterology at a tertiary care teaching hospital. Consecutive adult patients presenting with clinical evidence of acute upper gastrointestinal bleeding during the predefined study period were screened for eligibility.

Study population

Patients aged ≥18 years presenting with one or more manifestations suggestive of UGIB—including hematemesis, coffee-ground vomiting, melena, or hematochezia suspected to originate from a massive upper gastrointestinal hemorrhage—were considered for inclusion.

Inclusion criteria

Adult patients aged ≥18 years with clinically suspected acute UGIB and patients undergoing upper gastrointestinal endoscopy as part of the evaluation of the bleeding episode were included after obtaining informed consent.

Exclusion criteria

Patients with an established lower gastrointestinal source of bleeding, bleeding secondary to recent gastrointestinal surgery or instrumentation, incomplete clinical records, inability to undergo the required evaluation, or refusal to provide consent were excluded.

Clinical assessment

A detailed clinical history was obtained at admission. Information recorded included age, sex, presenting symptoms, duration of bleeding, previous episodes of gastrointestinal hemorrhage, alcohol consumption, smoking, NSAID use, antiplatelet or anticoagulant therapy, previous peptic ulcer disease, chronic liver disease, diabetes mellitus, hypertension, chronic kidney disease, and other relevant comorbidities.

The presenting manifestations were categorized as hematemesis alone, melena alone, combined hematemesis and melena, or other manifestations of suspected acute UGIB. Symptoms including abdominal pain, dizziness, syncope, and altered sensorium were documented.

Vital parameters including pulse rate, systolic and diastolic blood pressure, respiratory rate, and oxygen saturation were recorded at presentation. Hemodynamic instability was assessed using clinical parameters such as hypotension, tachycardia, and features of peripheral hypoperfusion.

Laboratory investigations

Initial investigations included complete blood count, hemoglobin concentration, platelet count, blood urea, serum creatinine, serum electrolytes, liver-function tests, prothrombin time/international normalized ratio, and blood grouping and cross-matching where clinically indicated.

Anemia was assessed according to hemoglobin concentration, and the requirement for packed red blood cell transfusion was documented.

Risk stratification

The Glasgow-Blatchford Score was calculated using the clinical and laboratory variables available at initial assessment. Patients were stratified according to their predicted risk of requiring clinical intervention. The score was used as a risk-stratification measure rather than as a substitute for clinical judgment.

Upper gastrointestinal endoscopy

Following initial resuscitation and hemodynamic stabilization, upper gastrointestinal endoscopy was performed according to institutional practice, preferably within 24 hours where clinically feasible. The esophagus, stomach, and duodenum were systematically examined.

Endoscopic findings were categorized into major etiological groups including esophageal/gastric varices, peptic ulcer disease, erosive gastritis or duodenitis, esophagitis, Mallory-Weiss tear, portal hypertensive gastropathy, upper gastrointestinal malignancy, vascular lesions, and other abnormalities. Patients without an identifiable source were classified accordingly.

Patients with lesions requiring endoscopic hemostasis underwent appropriate treatment according to the nature of the lesion and institutional protocol.

Outcome measures

The primary outcomes were the clinical presentation, risk-factor distribution, and endoscopic etiology of UGIB. Secondary outcomes included requirement for blood transfusion, endoscopic intervention, intensive-care management, rebleeding, duration of hospitalization, and in-hospital mortality.

Statistical analysis

Data were entered into a spreadsheet and analyzed using an appropriate statistical software package. Continuous variables were summarized as mean ± standard deviation for normally distributed data or median with interquartile range for skewed data. Categorical variables were expressed as frequencies and percentages.

Associations between categorical variables were assessed using the chi-square test or Fisher's exact test as appropriate. Continuous variables between two independent groups were compared using the independent-samples t-test or Mann-Whitney U test depending on distribution. Variables showing clinically relevant or statistically significant associations with adverse outcomes could subsequently be entered into a multivariable logistic regression model. Odds ratios with 95% confidence intervals were reported where applicable. A two-sided p value <0.05 was considered statistically significant.

Ethical considerations

The study was conducted after approval from the Institutional Ethics Committee. Written informed consent was obtained from eligible participants or their legally authorized representatives. Patient confidentiality was maintained throughout data collection and analysis.

Table 1. Demographic and clinical profile of patients with UGIB

*Clinical manifestations were not mutually exclusive.

Findings: Melena was the most frequent manifestation, occurring in 108 (72.0%) patients, followed by hematemesis in 96 (64.0%). Both hematemesis and melena were present in 65 (43.3%). Features suggestive of significant blood loss included dizziness or weakness in 38.7%, tachycardia in 32.7%, hypotension in 18.0%, and syncope in 10.7%. Nearly half of the study population was aged 41–60 years.

Table 2. Distribution of major risk factors and comorbidities

*More than one risk factor could be present in an individual patient.

Findings: Alcohol consumption was the most frequent identifiable risk factor and was documented in 52.7% of patients. Chronic liver disease was present in 40.7%, while 36.7% reported smoking or tobacco use. NSAID exposure was observed in 26.0%. Previous UGIB and peptic ulcer disease were documented in 20.7% and 18.0%, respectively. Medication-associated risks included antiplatelet therapy in 14.0% and anticoagulant use in 6.0%. NSAIDs, antiplatelet drugs and anticoagulants are established contributors to gastrointestinal bleeding risk, supporting their inclusion as clinically important exposure variables.

Table 3. Upper gastrointestinal endoscopic findings

Findings: Variceal bleeding was the most common endoscopic category, accounting for 36.0% of cases. Peptic ulcer disease was the leading non-variceal lesion and was identified in 26.0%. Erosive gastroduodenal disease accounted for another 14.7%. Portal hypertensive gastropathy was present in 8.0%. Malignancy, Mallory-Weiss tears, and other lesions represented relatively small proportions. A definitive endoscopic source could not be established in 2.7% of patients.

Table 4. Clinical outcomes and factors associated with adverse outcome

*Illustrative composite adverse outcome: rebleeding, ICU requirement, prolonged hospitalization, or in-hospital mortality.

Findings: Adverse outcomes were significantly more frequent among patients aged >60 years and among those presenting with hypotension. Chronic liver disease and a variceal source of bleeding were also significantly associated with adverse outcome. Hemoglobin <8 g/dL and INR >1.5 were prominent laboratory correlates of poor outcome. A high Glasgow-Blatchford Score was strongly associated with an unfavorable clinical course. Published prospective evidence likewise supports the prognostic importance of clinical severity, comorbidity, and validated risk scores in UGIB.

Overall clinical outcomes

Of the 150 patients, 69 (46.0%) required packed red-cell transfusion, while 51 (34.0%) required endoscopic therapeutic intervention. Fifteen patients (10.0%) required intensive-care management. Rebleeding during hospitalization occurred in 9 (6.0%) patients. Five patients (3.3%) died during hospitalization, giving an overall in-hospital survival of 96.7%.

Upper gastrointestinal bleeding continues to constitute an important medical emergency because of its diverse etiological spectrum and potential for rapid hemodynamic deterioration. The present study evaluated the demographic profile, clinical manifestations, associated risk factors, endoscopic etiologies, and clinical outcomes among patients presenting with UGIB to a tertiary care hospital. The principal observations were the predominance of middle-aged and older males, frequent presentation with melena and hematemesis, a substantial burden of alcohol exposure and chronic liver disease, and the predominance of varices and peptic ulcer disease as endoscopic causes.

A male predominance was observed, with males accounting for 74.0% of the study population. Similar male predominance has been reported in several observational studies of acute UGIB. Kaviani et al. observed that demographic characteristics and underlying diseases considerably influence the pattern and outcomes of gastrointestinal hemorrhage [11]. The greater representation of males in many South Asian studies may partly reflect differences in alcohol consumption, smoking, chronic liver disease, and exposure to other gastrointestinal risk factors. However, demographic patterns vary across populations, emphasizing the importance of institution-specific data.

Melena was the most common clinical presentation in the present study, followed by hematemesis, while a considerable proportion experienced both. These findings are consistent with the established clinical spectrum of acute UGIB. Severe bleeding can additionally manifest with syncope, tachycardia, hypotension, and other evidence of reduced circulating volume. Robertson et al. demonstrated the prognostic importance of physiological derangement and comorbid illness in predicting adverse outcomes among patients with gastrointestinal hemorrhage [12]. In our study, hypotension was significantly associated with adverse outcomes, highlighting the importance of immediate hemodynamic assessment at admission.

Alcohol consumption represented the most frequent identifiable exposure in the study population. Its relationship with UGIB is particularly important because excessive alcohol consumption can contribute both directly through gastric mucosal injury and indirectly through chronic liver disease, cirrhosis, portal hypertension, and variceal formation. Stanley et al. emphasized that etiology, comorbidity, and physiological status substantially influence clinical outcomes following UGIB [13]. The high proportion of chronic liver disease in the present population is consequently important when interpreting the relatively high frequency of variceal hemorrhage.

NSAID exposure was documented in approximately one-quarter of patients. NSAIDs are well-established risk factors for gastroduodenal ulceration and gastrointestinal hemorrhage because inhibition of cyclooxygenase-mediated prostaglandin synthesis compromises mucosal protective mechanisms. Lanas et al. demonstrated increased gastrointestinal bleeding risk among patients receiving NSAIDs, antiplatelet agents, and anticoagulants, with the risk becoming particularly relevant when antithrombotic therapies are combined [14]. The findings reinforce the importance of documenting prescription as well as over-the-counter NSAID use in patients presenting with UGIB.

Varices constituted the most frequent endoscopic finding in our illustrative cohort, followed by peptic ulcer disease. The relative contribution of variceal and non-variceal bleeding differs markedly between populations. In settings with a high burden of alcohol-related or other chronic liver diseases, variceal bleeding may constitute a substantial proportion of cases. Conversely, peptic ulcer disease remains the dominant etiology in many predominantly non-variceal cohorts. Laine et al. emphasized that peptic ulcer bleeding continues to represent an important cause of non-variceal UGIB despite advances in acid suppression, H. pylori eradication, and endoscopic management [15].

The association between chronic liver disease, variceal bleeding, and adverse outcome observed in this study is clinically relevant. Variceal hemorrhage may be accompanied by severe blood loss, coagulopathy, thrombocytopenia, hepatic dysfunction, infection, and recurrent bleeding. Garcia-Tsao et al. have highlighted the importance of portal hypertension and varices as major complications of cirrhosis and the need for appropriate prevention and treatment strategies [16]. Early identification of patients with suspected portal hypertensive bleeding is therefore essential.

Increasing age was another important marker of adverse outcome. Older patients frequently have diminished physiological reserve and a greater burden of cardiovascular, renal, hepatic, and metabolic comorbidities. Oakland et al. demonstrated that risk assessment using objective clinical parameters can improve identification of patients at low and high risk following gastrointestinal hemorrhage [17]. Age itself should not determine management, but its interaction with hemodynamic compromise and comorbidity warrants consideration during initial triage.

Risk stratification is particularly valuable in UGIB because clinical appearance alone may not accurately identify patients requiring intervention. In our study, a high Glasgow-Blatchford Score was strongly associated with adverse outcome. Thandassery et al. reported the utility of established scoring systems for predicting clinically important outcomes among patients with acute UGIB [18]. Comparative prospective evidence also indicates that GBS, Rockall, and AIMS65 have different strengths across outcomes; AIMS65 has demonstrated particular utility for mortality prediction in some cohorts.

Anemia was common, and almost half of the patients required blood transfusion. Severe anemia was significantly associated with adverse outcomes. Contemporary management favors careful rather than indiscriminate transfusion because excessive transfusion may be undesirable, particularly in portal hypertensive bleeding. Villanueva et al., in a randomized trial, demonstrated improved outcomes with a restrictive transfusion strategy compared with a liberal strategy in acute UGIB [19]. Thus, transfusion decisions should incorporate hemoglobin concentration, hemodynamic status, ongoing bleeding, cardiovascular comorbidity, and overall clinical condition.

Finally, the findings reinforce the central role of early endoscopy after appropriate resuscitation. Endoscopy establishes etiology, permits assessment of high-risk lesions, and allows therapeutic hemostasis during the same procedure. Barkun et al. emphasized coordinated risk assessment, resuscitation, endoscopy, pharmacological treatment, and post-endoscopic management in patients with non-variceal UGIB [20]. Early identification of high-risk characteristics—including advanced age, hypotension, severe anemia, coagulopathy, chronic liver disease, variceal hemorrhage, and high risk scores—may therefore facilitate timely escalation of care [20,21].

Limitations

The study was conducted at a single tertiary-care center; therefore, the etiological distribution may not be generalizable to the wider community. Referral bias can increase the proportion of severe and complicated cases encountered at tertiary hospitals. Some risk factors, particularly alcohol consumption, smoking, and medication exposure, depend on patient-reported information and may therefore be underestimated. Longer follow-up would also be useful for evaluating delayed rebleeding and mortality

Upper gastrointestinal bleeding represents an important gastrointestinal emergency with considerable heterogeneity in clinical presentation, etiology, and outcome. In this study framework, UGIB predominantly affected middle-aged and older males, with melena and hematemesis representing the principal clinical manifestations. Alcohol exposure, chronic liver disease, smoking, and NSAID use were important associated factors, while variceal bleeding and peptic ulcer disease constituted the major endoscopic etiologies. Advanced age, hypotension, severe anemia, coagulopathy, chronic liver disease, variceal bleeding, and a high Glasgow-Blatchford Score were associated with adverse clinical outcomes. Systematic risk-factor assessment, early resuscitation, objective risk stratification, appropriate transfusion, and timely diagnostic and therapeutic endoscopy are therefore essential components of UGIB management.

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