Etiology of upper gastrointestinal bleeding (UGIB) changed over recent decades

The etiology of upper gastrointestinal bleeding (UGIB) has undergone significant changes over the past few decades due to advancements in medical management and preventive strategies. UGIB, defined as bleeding originating from the esophagus, stomach, or duodenum, has experienced a decline in global incidence, largely driven by changes in the underlying causes and improved therapeutic interventions. Below is a detailed explanation of how the etiology has evolved:

### **Decline in Peptic Ulcer Disease (PUD) as a Major Cause**

• **Helicobacter pylori Eradication**: One of the most transformative changes in UGIB etiology has been the widespread eradication of *H. pylori*. This bacterium was historically a leading cause of peptic ulcer disease, which in turn was the most common cause of UGIB. With effective diagnostic tools and eradication therapies (e.g., antibiotics and PPIs), the prevalence of *H. pylori*-related ulcers has dramatically decreased, leading to fewer cases of ulcer-related bleeding.
• **Proton Pump Inhibitors (PPIs)**: PPIs have become a cornerstone in the prevention and treatment of acid-related injuries to the gastrointestinal mucosa. Their widespread use has reduced the risk of ulcers and bleeding associated with excessive stomach acid production.

### **Current Major Causes**

Despite the decline in *H. pylori*-related ulcers, peptic ulcer disease remains the leading cause of UGIB, accounting for 43.6% of cases. Other notable causes include:

1. **Gastritis and Duodenitis (27.6%)**: These inflammatory conditions of the stomach and duodenum are often associated with NSAID use, alcohol consumption, or stress-related mucosal damage.

2. **Esophageal Variceal Bleeding (8%)**: This remains a significant cause of UGIB, particularly in patients with liver disease and portal hypertension. Variceal bleeding has not declined as markedly as ulcer-related bleeding.

3. **Esophagitis (5.6%)**: Linked to gastroesophageal reflux disease (GERD), esophagitis has become a more prominent cause of UGIB in some populations.

4. **Less Common Causes**:

• **Malignancies**: Gastric or esophageal cancers can lead to bleeding, although these are less frequent causes.
• **Dieulafoy’s Lesions**: Rare vascular abnormalities that can cause severe bleeding.
• **Mallory-Weiss Tears**: Tears in the mucosa at the gastroesophageal junction due to forceful vomiting or retching.

### **Impact of Aging Populations and Medication Use**

• **Increased Use of NSAIDs, Anticoagulants, and Antiplatelet Agents**: These medications are associated with a higher risk of gastrointestinal bleeding. However, their impact on UGIB rates has been counterbalanced by the protective effects of *H. pylori* eradication and PPIs.
• **Aging Populations**: Older adults are more likely to use medications that predispose them to UGIB, yet the overall incidence has declined due to improved preventive strategies.

### **Improved Risk Mitigation**

The epidemiological shift in UGIB causes reflects advancements in gastroenterology:

• Better understanding of risk factors (e.g., *H. pylori*, NSAIDs, anticoagulants).
• Effective preventive measures, including eradication therapies and acid suppression with PPIs.
• Enhanced management of chronic liver disease and portal hypertension to reduce variceal bleeding.

### **Conclusion**

Over recent decades, the etiology of UGIB has shifted positively due to medical advancements. While peptic ulcer disease remains the predominant cause, its incidence has significantly declined owing to *H. pylori* eradication and widespread PPI use. Other causes, such as gastritis, duodenitis, and variceal bleeding, continue to contribute to UGIB cases, but overall, improved prevention and treatment have led to better outcomes and fewer cases of UGIB globally.