ORIGINAL ARTICLE

The Causes of Upper Gastrointestinal Bleeding

in the National Referral Hospital:
Evaluation on Upper Gastrointestinal Tract
Endoscopic Result in Five Years Period
Ari F Syam, M Abdullah, D Makmun, MK Simadibrata, D Djojoningrat,
C Manan, AA Rani, Daldiyono
Division of Gastroenterology, Department of Internal Medicine,
Faculty of Medicine University of Indonesia/Dr. Cipto Mangunkusumo General National Hospital

ABSTRACT
Backgrounds: Gastrointestinal bleeding such as hematemesis or melena are common conditions in
clinical practice and endoscopic service. The mortality rate due to gastrointestinal bleeding is relatively
high. In this study, we evaluate the causes of hematemesis melena for the last 5 years and the factors
associated with the bleeding.
Methods: The study was done retrospectively. We obtained data from medical record of patients that
performed endoscopy of upper gastrointestinal tract in Division of Gastroenterology, Department of
Internal medicine, Cipto Mangunkusumo hospital (Jakarta, Indonesia) during the period of 2001 to
2005.
Results: Of 4.154 patients who underwent upper gastrointestinal tract endoscopy from 2001 to 2005,
we found that 837 patients (20.1%) were due to upper gastrointestinal bleeding. They were 552 male
(65.9%) and 285 female patients (34.1%). Mean age of male patients was 52.7 ± 15.82 years, while for
female patients was 54.46 ± 17.6 years. Of 837 patients who came due to hematemesis were 150 patients
(17.9%), melena were 310 patients (37.8%), both melena and hematemesis were 371 patients (44.3%),
557 cases (66.5 %) due to non varices. Endoscopic results showed that 280 cases (33.4%) were due to
esophageal varices. In general, this study had demonstrated that esophageal varices was the most
frequent cause of upper gastrointestinal bleeding. We found 229 cases of esophageal varices were
coincidence with portal hypertensive gastropathy. While ulcer was found in 225 cases (26.9%) and most
of them were gastric ulcer (51.1%). Of gastrointestinal bleeding caused by esophageal varices, most were
grade III in 138 cases (49.3%). The incidence of bleeding of bleeding were found more frequently in
patients age group of 40 - 60 years (389 cases; 46.5%), > 60 years (305 cases; 36.2%), < 40 years
(242 cases; 16.8%). The causes of bleeding in patients whose age > 60 years, most were caused by ulcer
(37.4%). In this study, we also found that cancer as the cause of gastrointestinal bleeding in 26 cases
(3.1%). Gastrointestinal cancer comprised of gastric cancer in 15 cases (57.7%), duodenal cancer in
7 cases (26.9%), and esophageal cancer in 4 patients (15.4%).
Conclusion: The most frequent cause of upper gastrointestinal bleeding was esophageal varices and
usually had reached stage III. The non variceal cause of bleeding was gastric cancer. Upper
gastrointestinal malignancy was also found to be the etiology of bleeding in this study.

Keywords: upper gastrointestinal bleeding, endoscopy

INTRODUCTION complain of bloody emesis or black stool. These

Upper gastrointestinal bleeding is a common conditions require special attention since the first
emergency condition that makes patient goes to management in emergency room.
hospital. The prevalence and incidence of hematemesis Medical terms that are commonly used for
are still high. The patients usually come to hospital and gastrointestinal bleeding are hematemesis and melena.

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Ari F Syam, M Abdullah, D Makmun, MK Simadibrata, D Djojoningrat, C Manan, AA Rani,Daldiyono

Hematemesis is defined as “coffee ground” or bloody presence of protruding lesion, flat lesion, or excavated
emesis, while melena as black stool. Dark color of stool lesion as the source of bleeding. Evaluation of ulcer
depends on gastric acid concentration and contact included the number of ulcer, the form of ulcer or
between the blood and acid. In massive bleeding there the presence of bleeding stigmata based on FORREST
is not enough time for blood to mix with gastric acid, classification. Active ulcer hemorrhage is defined if
thus, there is fresh red colored blood in the stool.1 there was spurting vessel or oozing of blood (Ia).
In general, the cause of gastrointestinal bleeding Recent bleeding was defined if there was visible
can be divided into 2 groups; variceal and non variceal vessel (IIa) covered by clotting (IIb) or hematin in the
bleeding. Upper gastrointestinal bleeding may occur base of ulcer (IIc).
due to ulcer in gastrointestinal tract such as erosion, or Evaluation of esophageal varices included size of
bleeding ulcer. Other causes include rupture of the blood varices, the presence of red color sign in the surface
vessel like variceal rupture in the esophagus, fundus of ulcer indicating recent bleeding. Classification of size
and gastric cardia or Mallory-Weis tear in distal of varices was based on size and form of varices.
esophagus.1 In addition, carcinoma of esophagus, gaster Evaluation of gastric mucosa included luminal
and duodenum can also cause upper gastrointestinal content and mucosal condition. Evaluation of mucosa
bleeding. to observe the presence of protruding, flat and
The incidence of gastrointestinal bleeding presented excavated lesion. The presence of erosion or ulcer was
as hematemesis or melena are common condition in also evaluated. Evaluation of erosion was based on
endoscopic services. Data from our hospital the number andlocation of erosion. Patients with liver
demonstrated that almost 25% cases that performed cirrhosis were evaluated for portal hypertensive
upper gastrointestinal endoscopy were due to upper gastropathy indicated by the presence of mosaic-like
gastrointestinal bleeding.2 The frequent causes of pattern, scarlatina-like pattern and cherry red spots.
the bleeding were esophageal varices rupture, gastric In this study, if the source of bleeding was not found,
and duodenal ulcer. Besides, erosive gastritis was also then it was considered as not found which meant we
the etiology of gastrointestinal bleeding specially in didn’t find the source of bleeding.
patients who used NSAID. The mortality rate due to
upper gastrointestinal bleeding was still high reaching
STATISTICAL ANALYSIS
almost 26% based on study done in our hospital.3
In this study, we evaluate the causes of Descriptive data analysis was done to observe age
hematemesis melena in the last 5 years and related distribution, age group, sex, indications, and various
factors to the incidence of upper gastrointestinal endoscopic results by using statistic software.
bleeding.
RESULTS
METHODS Of 4,154 patients who underwent upper
This is a retrospective study by collecting data from gastrointestinal endoscopy during the period of
medical records of patients who underwent upper 2001-2005, we found 837 patients (20.15%) had upper
gastrointestinal endoscopy in the last 5 years gastrointestinal bleeding. The patients consists of 552
(2001-2005) in Endoscopy unit, Division of Gastroen- male (65.9%) and 285 female (34.1%). Mean of age
terology, Department of Internal Medicine in Cipto in the male group was 52.7 years (± 15.82), while in
Mangunkusumo hospital, Jakarta, Indonesia. the female group was 54.46 years (± 17.6).
During the period of 5 years, there were Of 837 patients, there were 150 patients (17.9%)
4,154 patients who underwent upper gastrointestinal who complained of hematemesis, 310 patients (37.8%)
endoscopy. Of 4,154 patients, there were 837 patients complained of melena, and 371 patients (44.3%)
(20.15%) who were indicated for endoscopy due to complained of both melena and hematemesis.
upper gastrointestinal bleeding. Endoscopic Result
Of 837 patients who had upper gastrointestinal From 837 patients who underwent upper
bleeding presented as hematemesis, melena or both gastrointestinal endoscopy, we found 557 patients
were evaluated. The evaluation included age, sex, (66.5%) were due to non variceal cause and the rest
endoscopy indication, and endoscopic results. in 280 patients (33.5%) due to variceal cause as seen
Endoscopic diagnosis was made based on in table 1. In general this study had demonstrated that
evaluation of esophageal, gastric and duodenal mucosa esophageal varices are the most frequent cause of
according to the OMED criteria. upper gastrointestinal bleeding; 280 cases (33.4%).
Endoscopic evaluation based on luminal content; Of all cases due to variceal bleeding, most of them
the presence of fresh blood, clotting and hematin or were esophageal varices grade III; 138 cases (49.3%).
clean lumen. Evaluation of mucosa included the Esophageal varices grade II accounted for 61 cases

72 The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy

The Causes of Upper Gastrointestinal Bleeding in the National Referral Hospital:Evaluation on Upper Gastrointestinal Tract Endoscopic Result in
Five Years Period

(21.8%), while grade IV 50 cases (17.9%), grade I 20 found in age group of 40-60 years; 389 cases (46.5%).
cases (7.1%), gastric varices 6 cases (2.1%) and In age group of > 60 years we found 305 cases
obliterated varices 5 cases (1.8%). (36.2%), < 40 years were 141 cases (16.8%). If we
In patients with upper gastrointestinal bleeding due observed the etiology of bleeding in patients whose age
> 60 years, most were ulcer (50.9%) as seen in
table 3.
Table 1. Diagnosis of upper gastrointestinal endoscopy on
indication of hematemesis, melena, or both In patients with esophageal varices, ligation or
Number of Percentage
Diagnosis
patients (%) Table 3. Age distribution in patients with peptic ulcer
Varices 280 33.5 Age group (years) Number of cases Percentage (%)
Peptic ulcer 225 26.9
Erosive gastritis 219 26.2 < 40 21 9.4
40-60 89 39.7
Not found 38 4.5
> 60 114 50.9
Esophagitis 20 2.4
Portal hypertensive gastropathy** 15 1.8 Total 224 100.0
Polyp 11 1.3
Cancer 26 3.1
Miscellaneous* 3* 0.4 sclerotheraphy were done immediately in 126 cases
Miscellaneous*: Hemangioma, diverticulosis. Portal hypertensive (45%), while in the rest of cases these procedures were
gastropathy**: found in coincidence with esophageal varices in
229 cases (27.4%) performed later.

Table 2. Grade and type of varices on endoscopic

DISCUSSION
evaluation of upper gastrointestinal bleeding
Upper gastrointestinal bleeding is a common cause
Number of cases
Varices type
(Percentage)
that makes patient goes to the doctor. Endoscopic
Esophageal varices grade 1 20 (7.1)
evaluation is required to identify the source of
Esophageal varices grade 2 61(21.8) bleeding. The high prevalence of chronic hepatitis B
Esophageal varices grade 3 138 (49.3)
Esophageal varices grade 4 50 (17.9) and increasing number of hepatitis C in Indonesia in
Gastric varices 6 (2.1) the end make the incidence of liver cirrhosis is also
Obliterated varices 5 (1.8)
Total 280 (100)
increasing. Thus, if there were patients who come to
hospital due to gastrointestinal bleeding, we should
always consider rupture of esophageal varices as
to non variceal causes, we found ulcer in 225 cases the etiology.
(26.9%), erosive gastritis in 219 cases (26.2 %), no In this study, we found incidence of upper gastro
localization in accordance with operational definition intestinal bleeding were more frequent in male (66.3%).
of study in 38 cases (4.5%), esophagitis in 20 cases This result was in accordance with study done b y
(2.4%), and portal hypertensive gastropathy in 15 cases Zaltman et al. who found incidence in male patients
(1.8%). Most of ulcers were gastric ulcer in 115 cases was 68.7%.4 Rockel et al found that incidence of
(51.1%). The rest were duodenal ulcer in 78 cases upper gastrointestinal in male was twice than in
(34.7%), gastric ulcer and duodenal ulcer in 22 cases female.5
(9.8%) and esophageal ulcer in 10 cases (4.4%). If we observed on patients age, 36.2% of them
In this study, portal hypertensive gastropathy in were more than 60 years old. It showed upper
coincidence with esophageal varices were found in gastrointestinal bleeding was relatively frequent in
229 cases (27.4%). elderly patients. This data supported the reference that
We also found that cancer as the etiology in 26 cases mentioned higher risk of bleeding in patients > 60 years
(3.1%) of all cases of gastrointestinal bleeding which old.6 Patients whose age > 60 years increased
performed upper gastrointestinal endoscopy. mortality risk. On the other hand, most of diagnosis
The frequent cancer lesions subsequently were which made in those patients were peptic ulcer and
gastric cancer in 15 cases (15.4%), duodenal cancer varices.
in 4 cases (15.4%). In this study, there was no In this study, we found the symptom of hematemesis
significant difference of mean age between group of only was found in 17.9% patients, while Zaltman et al
patients with cancer and no cancer (p=0.114). Besides, found 30.1%.This indicated that patients who came to
sex was not different significantly between those our hospital were late because most of patients with
2 groups (p = 0.221). hematemesis came after melena occurred (44.3%).
In this study, we found 11 cases of polyp consisted of In this study, we found peptic ulcer whether in
gastric polyp (54.5%) and the rest were duodenal gaster or duodenum or both or combination of each
polyp in 5 cases (45.5%). location was found in 224 cases (26.8%). The number
The incidence of bleeding was more frequently of incidence of ulcer was lower than study done by

Volume 6, Number 3, December 2005 73

Ari F Syam, M Abdullah, D Makmun, MK Simadibrata, D Djojoningrat, C Manan, AA Rani,Daldiyono

Zaltman et al in one of hospital in Brazil; South America Internal Medicine. 14th ed. New York: Mc Graw Hill Inc
which found incidence of ulcer was 39.77%. 1998.p.246-9.
2. Ari F Syam, Abdullah M, D Makmun, MK Simadibrata,
However, if we compare to other study by Mahadeva D Djojoningrat, B Hegar, C Manan, AA Rani, Daldiyono.
in UK had found the incidence of peptic ulcer was as The evaluation of upper gastrointestinal endoscopies:
low as 21 % from 872 patients who underwent indication and results. J Gastroenterol Hepatol
endoscopy on indication of upper gastrointestinal 2003;18(suppl):A71.
3. Djojoningrat D. Hematemesis Melena sebagai keadaan gawat
bleeding.7
darurat di bidang Gastroenterologi. Dalam: Markum HMS,
The incidence of varices in this study is higher Sudoyo A, Effendy S, Setiati S, Gani RA, Alwi I (editors).
(33.5%) compare to study done by Zaltman which Naskah lengkap Pertemuan Ilmiah Tahunan Ilmu Penyakit
found only 18.75% of cases. In this study, rupture of Dalam 1997 Jakarta. Bagian IPD FKUI/RSCM 1997.
esophageal varices is the main cause of upper h.189-94.
4. Zaltman C, Souza HS, Castro ME, Sobral Mde F, Dias PC,
gastrointestinal bleeding. Esophageal varices is Lemos V Jr. Upper gastrointestinal bleeding in a Brazilian
usually caused by liver cirrhosis due to chronic hospital: a retrospective study of endoscopic records.
nfection of hepatitis B virus or hepatitis C virus. This Arq Gastroenterol 2002;39:74-80.
had considered the high prevalence of chronic 5. Rockall TA, Logan RF, Devlin HB, Northfield TC. Incidence
of and mortality from acute upper gastrointestinal haemorrhage
hepatitis B in Indonesia. If we looked further, it was
in the United Kingdom. Br Med J 1995;311:222-6.
clearly shown that about half of cases of variceal 6. Palmer K. Management of haematemesis and melena. Postgrad
bleeding were due to grade 3 varices. This finding is in Med J 2004;80:399-404.
accordance with the fact that the bigger size of 7. Mahadeva S, Linch M, Hull M. Variable use of endoscopic
varices will increase the risk of bleeding.8 haemostasis in the management of bleeding peptic ulcers.
Postgrad Med J 2002;78:347-51.
Further evaluation of peptic ulcer showed that 8. Sharara AI, Rockey DC. Gastroesophageal variceal
incidence of peptic ulcer was less than 50% as non hemorrhage. N Engl J Med 2001;345:669-81.
variceal cause of gastrointestinal bleeding. This also 9. Barkun A, Bardou M, Marshall JK. Consensus
demonstrated that the incidence of peptic ulcer was recommendations for managing patients with non variceal
upper gastrointestinal bleeding. Ann Intern Med 2003;139:
lower than other local centers which had got 50 - 70%
843-57.
of patients with peptic ulcer as non variceal cause of 10. Yavorski RT, Wong RK, Maydonovitch C, Battin LS, Furnia
bleeding.9 If we analyzed furthermore, patients with A, Amundson DE. Analysis of 3,294 cases of upper
peptic ulcer were those whose age was more than gastrointestinal bleeding in military medical facilities. Am J
60 years old. This showed that age was important Gastroenterol 1995;90:568-73.
factor to be considered in determine the cause of
gastrointestinal bleeding.
In this study, we also found that gastrointestinal
cancer as the cause of upper gastrointestinal bleeding
reached 3.1%. This data demonstrated the importance
of endoscopy as diagnostic tool in gastrointestinal
bleeding.

CONCLUSIONS
In this retrospective study, we found that
esophageal varices is the most frequent cause of
patients who came to our national referral hospital.
Band ligation or sclerotheraphy could be performed
immediately in most of cases. The cause of bleeding
could be identified in almost all cases.
This study had proven that endoscopy is
an important diagnostic tool that should be performed
immediately to identify the cause of upper
gastrointestinal bleeding to determine appropriate
treatment for the patients. Thus, death due to upper
gastrointestinal bleeding can be prevented.

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74 The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy