Acute Upper Gastrointestinal Bleeding (AUGIB) continues to be one of the most common medical emergencies encountered in hospital settings worldwide. It often necessitates urgent care, endoscopic intervention, and can be associated with considerable morbidity and mortality if not managed promptly. AUGIB encompasses bleeding from the oesophagus, stomach, or proximal duodenum and typically presents as hematemesis, melena, or both [1].

Peptic ulcer disease and variceal haemorrhages remain the predominant causes, accounting for approximately 45–60% and 6–39% of AUGIB cases respectively [2]. Advances in diagnostic and therapeutic modalities over the past two decades, particularly the widespread adoption of early endoscopy and the use of risk stratification scores, have markedly improved patient outcomes [3]. Tools such as the Glasgow-Blatchford Score (GBS) and the Rockall Score are now routinely employed to guide admission, predict outcomes, and determine the need for intervention [4].

Despite these advancements, AUGIB remains a significant cause of hospitalization, with an estimated global incidence ranging between 100 and 150 per 100,000 population per year [2]. Mortality, although decreased, continues to range from 3% to 14% depending on etiology, comorbidities, and timing of treatment [2]. NSAID use and Helicobacter pylori infection have been closely associated with the pathogenesis of peptic ulcers, and eradication of H. pylori has significantly reduced ulcer recurrence and bleeding complications [5].

Multiple studies conducted globally have shown varying prevalence patterns. For instance, Kim et al. in the United States reported that ulcers and varices each accounted for about one-third of UGIB cases [6]. In a prospective study from Uganda, oesophageal varices were the most common cause (40.6%) [7], while in Iran, gastric and duodenal ulcers together were the leading causes (44%) [8]. Studies from India have highlighted the predominance of peptic ulcer bleeding in some regions and variceal bleeding in others, likely reflecting differences in H. pylori prevalence, liver disease burden, and NSAID use [9,10].

Given the clinical importance of UGIB and the geographical variation in its causes and outcomes, this study was undertaken to analyze the etiological spectrum and patient outcomes in a tertiary care hospital setting in Eastern India. The findings aim to contribute to a region-specific understanding of this condition and support risk-based management strategies in similar healthcare environments.

Aims and Objectives

The aim of this study was to evaluate the etiology and outcome of patients presenting with upper gastrointestinal bleeding (UGIB) in a tertiary care hospital setting.

Specific Objectives:

1. To identify the causes of upper gastrointestinal bleeding using clinical and endoscopic evaluation.
2. To assess the severity of UGIB using validated scoring systems—Glasgow-Blatchford Score (GBS) and Rockall Score.
3. To determine the clinical outcomes, including duration of hospital stay, referral needs, and mortality, in relation to the severity of bleeding and etiology.

Study Design and Setting

This was a descriptive observational study conducted at the Department of General Medicine, Calcutta National Medical College and Hospital, Kolkata, a tertiary care teaching hospital in Eastern India. The study was carried out over a 12-month period, from February 2019 to January 2020.

Study Population

A total of 100 patients presenting with clinical signs of upper gastrointestinal bleeding (UGIB)—including hematemesis, melena, or both—were included. Patients were enrolled based on the following criteria:

Inclusion Criteria

• Adult patients (age ≥18 years) presenting with signs of acute UGIB
• Consent to undergo upper gastrointestinal endoscopy and participate in the study

Exclusion Criteria

• Patients with lower gastrointestinal bleeding
• Known bleeding disorders (e.g., haemophilia)
• Patients on anticoagulation therapy
• Patients who refused endoscopy or did not consent to participate

Data Collection

A pre-designed case record form was used to collect information on:

• Demographic details (age, sex)
• Clinical presentation (hematemesis, melena, syncope)
• Past medical history, including known peptic ulcer disease, liver disease, NSAID or alcohol use
• Laboratory parameters including hemoglobin levels
• Endoscopic findings
• Outcome data (hospital stay, need for referral, mortality)

Risk Assessment Tools

Each patient was assessed using two validated scoring systems:

• Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification
• Rockall Score for post-endoscopy risk and prognosis

These scores were calculated using clinical and endoscopic parameters including systolic blood pressure, hemoglobin level, age, comorbidities, and endoscopic lesion characteristics.

Diagnostic Procedure

All patients underwent upper gastrointestinal endoscopy using a standard video gastroscope after initial stabilization. Endoscopic diagnoses were recorded, and therapeutic interventions, if needed, were administered as per standard protocol.

Statistical Analysis

Data were compiled and analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics such as mean, standard deviation, frequency, and percentage were used. Comparative analyses were performed using chi-square tests to identify statistically significant associations between variables such as endoscopic severity, Rockall score, duration of stay, and outcomes. A p-value < 0.05 was considered statistically significant.

Ethical Considerations

The study protocol was reviewed and approved by the Institutional Ethics Committee. Informed consent was obtained from all participating patients prior to inclusion.

1. Baseline Characteristics of the Study Population

A total of 100 patients presenting with upper gastrointestinal bleeding were enrolled in the study. The mean age of presentation was 45.26 years, with the majority of patients falling within the 35–49 year age group, accounting for 48% of cases. Patients aged below 35 years comprised 20%, those between 50–64 years constituted 22%, and only 10% were aged 65 years or above. This suggests a significant disease burden among middle-aged adults.

There was a marked male predominance, with 79% of patients being male and only 21% female, resulting in a male-to-female ratio of approximately 3.8:1. This gender disparity may reflect the higher prevalence of risk factors such as alcohol consumption, smoking, and NSAID use among males in the studied population.

Table 1A: Age Distribution of Patients

Table 1B: Gender Distribution of Patients

2. Clinical Presentation and Risk Factors

The most common mode of presentation among patients with upper gastrointestinal bleeding was a combination of hematemesis and melena, reported in 65% of cases. Hematemesis alone was noted in 28% of patients, while melena alone accounted for 7%. A small proportion (9%) also reported syncope associated with their bleeding episode, indicating possible hypovolemia or hemodynamic instability at presentation as shown
in Table 2A.

Analysis of predisposing risk factors revealed that alcohol use was the most prevalent, present in 50% of the study population. Smoking (44%) and NSAID use (22%) were also commonly implicated, consistent with their known roles in mucosal injury and ulcerogenesis. Notably, 30% of patients had underlying liver disease, and 12% had a previous history of peptic ulcer disease (PUD). In 8% of cases, no identifiable risk factor was reported, as detailed in Table 2B

These findings underscore the multifactorial etiology of UGIB and highlight modifiable lifestyle factors—particularly alcohol and NSAID consumption—as important targets for prevention strategies.

Table 2A: Clinical Presentation of UGIB

Table 2B: Risk Factors in Patients with UGIB

3. Endoscopic Findings

Upper gastrointestinal endoscopy revealed that peptic ulcer disease remained the most common etiology of bleeding, with gastric ulcers and duodenal ulcers each identified in 24% of patients. An additional 4% of patients had both gastric and duodenal ulcers concurrently, underscoring the high prevalence of acid-peptic disorders as a cause of UGIB.

Oesophageal varices, either alone or in combination with portal hypertensive gastropathy (PHG) or gastric antral vascular ectasia (GAVE), were identified in a combined 24% of patients. Specifically, oesophageal varices alone accounted for 15%, varices with PHG for 6%, and varices with GAVE for 3%. Other notable findings included esophagitis in 6%, carcinoma of the stomach in 3%, Mallory-Weiss tears in 2%, and a normal endoscopic study in 4% of patients, as detailed in Table 3. This gender-based distribution of endoscopic lesions is further illustrated in Figure 1, which shows a clear male predominance across nearly all lesion types, particularly in peptic ulcer disease and esophageal varices.

This distribution reflects a dual burden of peptic ulcer-related and portal hypertension-related bleeding in the studied population, highlighting the importance of endoscopy in both diagnosis and risk stratification.

Table 3: Endoscopic Findings in Patients with UGIB

Bar chart comparing the number of male and female patients across different endoscopic findings. Gastric and duodenal ulcers were predominantly observed in males. Esophageal varices and associated portal hypertensive lesions also showed male predominance, while lesion frequency in females was comparatively lower across all categories.

4. Severity Assessment Using Glasgow-Blatchford and Rockall Scores

Risk stratification of patients with upper gastrointestinal bleeding was performed using the Glasgow-Blatchford Score (GBS) and the Rockall Score, two validated prognostic tools for UGIB.

The GBS distribution showed that 89% of patients had scores ≥6, indicating a high probability of requiring clinical intervention. Only 11% fell into the intermediate risk category (scores 3–5), while none had scores in the 0–2 range, reflecting the acute nature of the bleeding episodes in the study cohort, as shown in Table 4A.

Similarly, the post-endoscopy Rockall Score revealed that the majority of patients (81%) belonged to the moderate risk category (scores 3–7). Low-risk patients (scores 0–2) accounted for 11%, while 8% of patients had scores ≥8, classifying them as high-risk, as detailed in Table 4B. This distribution is visually represented in Figure 2, where the majority of patients fall within the moderate-risk Rockall category (scores 3–7), with smaller proportions classified as low or high risk.

These scoring patterns affirm the utility of GBS and Rockall systems in identifying high-risk patients who require intensive monitoring, endoscopic therapy, or referral.

Table 4A: Glasgow-Blatchford Score (GBS) Distribution

Table 4B: Rockall Score Distribution

Pie chart showing that 81% of patients were in the moderate-risk category (scores 3–7), while 11% and 8% were categorized as low (0–2) and high risk (≥8), respectively. This distribution emphasizes the predominance of moderate severity in this cohort.

5. Clinical Outcomes

Following appropriate medical and endoscopic management, 94% of patients were successfully discharged. A small proportion (6%) required referral to a higher centre due to the need for advanced intervention or specialist care. Notably, there were no reported deaths among the 100 patients included in the study, reflecting effective stabilization and treatment protocols during the hospitalization period, as detailed in Table 5.
These findings suggest that, when promptly recognized and appropriately managed, UGIB outcomes can be favourable, even among patients with moderate-to-high risk scores on admission.

Table 5: Clinical Outcomes of Patients with UGIB

Bar chart demonstrating the association between Rockall risk categories and patient outcomes. All patients in the low-risk group were discharged. Most moderate-risk patients were discharged, with a small number referred. High-risk patients showed a higher proportion of referral, highlighting the score’s predictive value for care escalation.

6. Hospital Stay and Association with Lesion Severity

The average duration of hospital stay was directly associated with the severity of endoscopic findings. Patients with mild lesions had a mean stay of 2.2 days, those with moderate lesions stayed an average of 4.8 days, and patients with severe lesions had a mean hospital stay of 7.0 days, as shown in Table 6.

This association was found to be statistically significant (p < 0.001), underscoring the clinical relevance of early endoscopic severity grading in anticipating hospitalization needs and planning appropriate resource allocation. This trend is clearly visualized in Figure 4, where lesion severity is shown to have a direct impact on the length of hospital stay.

Table 6: Hospital Stay by Lesion Severity

Bar chart showing a progressive increase in hospital stay duration with rising lesion severity. Patients with mild lesions had the shortest stays, while those with severe lesions required significantly longer hospitalization.

The current study explored the clinical spectrum, risk factors, endoscopic findings, and outcomes among patients with upper gastrointestinal bleeding (UGIB). Male predominance (79%) noted in our cohort is consistent with previous reports such as the RUGBE database (62%) and the work of Longstreth et al., who reported a 67.9% male predominance in their study population [11,12]. Similarly, Rockall et al. also documented male predominance of 57% [13].

In terms of age distribution, nearly half (49%) of the patients in this study fell within the 35–49 years age range. This contrasts with the findings of Longstreth et al., who reported that 47% of UGIB cases occurred in patients over 65 years of age, suggesting a relatively younger demographic in our study context [12].

Regarding presenting symptoms, hematemesis alone was observed in 50% of cases, while a combined presentation with melena occurred in 43% of cases. These findings differ slightly from those of Longstreth et al., who reported hematemesis in only 33% and melena in 81% of cases, and from the RUGBE dataset, which found hematemesis in 58% and melena in 69% [11,12].

Endoscopic evaluation revealed peptic ulcer disease as the most common etiology of UGIB (48%), consistent with the RUGBE study which reported a 56% incidence [14]. Esophageal varices and related portal hypertension lesions were the second most common cause, seen in 30% of patients. Other lesions included esophagitis (6%), carcinoma of the stomach (3%), and Mallory-Weiss tears (2%), closely mirroring prior observations by Rockall et al., who reported peptic ulcer disease in 36.1%, malignancy in 4%, and Mallory-Weiss tears in 5.1% of cases [13].

The use of risk scores such as the Glasgow-Blatchford Score (GBS) and Rockall Score proved crucial for patient stratification. Most of our patients (89%) had a GBS ≥6, denoting high intervention needs. The Rockall score similarly identified a large proportion (81%) in the moderate-risk category, aligning with previous literature suggesting the score’s effectiveness in predicting clinical outcomes and guiding management decisions [13,14].

Hospital stay duration correlated significantly with lesion severity. Patients with severe lesions stayed a mean of 7 days, those with moderate lesions 4.8 days, and mild cases only 2.2 days. These findings affirm the Rockall score’s prognostic value and its relevance to clinical resource allocation.

Outcomes were generally favourable, with 94% of patients discharged and only 6% referred to higher centres. No deaths were reported in this cohort, which may reflect improved early risk assessment and management, echoing findings from studies showing reduced mortality in settings with standardized protocols [14,15].

Limitations

This study was conducted at a single tertiary care centre with a relatively small sample size (n=100), which may limit the generalizability of the findings. The cross-sectional design restricts the ability to assess long-term outcomes or recurrence of bleeding. Additionally, some variables such as H. pylori status and detailed medication history (e.g., anticoagulant use) were not evaluated, which could influence bleeding risk and etiology.

Peptic ulcer disease and esophageal varices emerged as the leading causes of upper gastrointestinal bleeding in this Eastern Indian tertiary care setting. Most patients presented with moderate to high severity scores, and endoscopy played a pivotal role in both diagnosis and risk stratification. Clinical outcomes were favourable with appropriate early intervention, and no mortality was recorded. The Glasgow-Blatchford and Rockall scores proved to be effective tools for early risk assessment, helping to guide clinical decision-making and resource allocation.

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