The common causes of upper gastrointestinal bleeding (UGIB) include duodenal ulcer (DU), gastric ulcers (GU), erosive

mucosal disease (EMD), varices of portal hypertension (PHTN) and Mallory-Weiss syndrome (MWS). Less common causes include oesophagitis, neoplasm, and angiodysplasia1. With a systematic management approach, nine out of ten patients with massive upper gastrointestinal bleed can ultimately be saved2. In the available data, at high altitude the incidence of peptic ulcer and haemorrhage from it is more as compared to the sea level3. The incidence of peptic ulcer disease rises in the winter season and declines in summer as reported in duodenal ulcer calendar by Hall et al4. The temperature at moderate altitude and at high altitude remains low, for each 150 metres rise in height, the temperature falls by 10 degrees Celsius, mimicking a prolonged winter season. It may be a physiological factor and alongwith altered blood rheology may be a contributing factor to high incidence of peptic ulcer at high altitude; though, splanchnic blood flow and metabolism are not modified by the life-long exposure to hypoxia5. The problem of upper GI bleeding is quite common, and our institution is situated at a moderate altitude of 2,200 metres from mean sea level (MSL), in the sub-Himalayan ranges of North India. It is a tertiary institute and most of the patients coming to it, are from an altitude of 2,000-3,000 MSL. There is limited data about upper gastrointestinal bleeding in relation to altitude, particularly of people living in Himalayan and Sub-Himalayan belt corresponding to high-to-moderate altitude (2,000-3,000 MSL ) of North India. This study was undertaken to know the various aspects of acute upper GI bleeding at our institution.

Introduction Bleeding from the GI tract may present in five ways. Haematemesis is vomitus of red blood or coffee ground material. Melaena is black, tarry, foul smelling stool. Haematochezia is the passage of bright red or maroon blood from rectum. Occult GI bleeding may be identified in the absence of overt bleeding by special examination of the stool (e.g. guaiac testing. Finally, patients may present only with symptoms of blood loss or anemia such as light- headedness, syncope, angina, or dyspnea.1 Upper GI bleeding refers to blood loss with in the intraluminal gastrointestinal tract form any location between the upper esophagus to the duodenum at the ligament of Treitz.2 If vomiting occurs shortly after the onset of bleeding, the vomitus appears red and later the appearance is dark red, brown, or black precipitated blood clots in the vomitus and produces a coffee ground appearance. Melaena develops after as little as 50100 ml of blood loss in upper gastrointestinal tract.

Melaena can occur with bleeding any lesion from areas proximal to and including the Caecum. Acute blood loss greater than 50-100 ml may produce melaena for as long as a week. After stool color returns to normal, the test for occult blood test may remain positive for over a week. Stool is black tarry and foul smelling. The black, tarry character of melaena is due to degradation of blood to hematin of other hemochromes by bacteria and should not be confused with greenish character of ingested iron or the black, non foulsmelling stool caused by ingestion of bismuth.6.haematemesis results from a combination of large amount of blood filling the stomach together with the urge to vomit. So haematemesis generally indicates a more severe bleeding episode than melaena. Clinical presentation depends on the site, extent and rate of haemorrhage and presence of coincidental disease. Bleeding from the upper GI tract is approximately five times more common than from lower gastrointestinal tract.3,4 It is more common in men and elderly people.3,4 The most common presenting features of upper gastrointestinal haemorrhage are haematemesis, melaena and shock.5 Acute upper gastrointestinal hemorrhage is the most important gastrointestinal emergency and is responsible for about 25,000 admissions to hospital each year in the UK. The incidence is 50150/10000/year and is the highest in areas of social deprivation. It appears that the overall incidence of admissions for upper gastrointestinal bleeding decreased in the UK. In Hong Kong, the incidence has decreased by 30% over the last 10 years. The mortality of patients admitted to hospital for acute gastrointestinal bleeding is about 10%; in the UK, crude mortality has not changed in more than half a century.6 In Thailand a review of 5000 patients of haematemesis and melaena revealed, peptic ulcer disease (51%), acute mucosal erosion (31.6%), normal study (2.46%).7 In Pakistan, a prospective study of 350 cases who presented with haematemesis endoscopic study of upper GIT of them revealed oesophageal varices in 24% and superficial mucosal lesion in 17% cases.8 Mortality from bleeding ulcers increased with age.9 The ASGE10 Survey data suggested that healthy patient less than 60 year old with no underlying disease has a mortality of only 2%.

However mortality from a first bleed from varices is around 50 % and most survivors re-bleed with inpatient mortality of about 30%. In Bangladesh many patients are admitted in different hospitals with haematemesis and melaena, but there is a little study on the etiology of the upper gastrointestinal haemorrhage, a survey study by Khan et al (19870 has revealed the point of prevalence of DU and GU was to be 11.9% and 3.6% respectively.11 Alam MT in his study on the etiology of upper gastrointestinal haemorrhage and its prognosis showed that- duodenal ulcer was the commonest cause of haematemesis and melaena followed by oesophageal varices, gastric ulcer and erosive gastritis. Within 12-24 hours of admission, endoscopy will detect12 the causes of haemorrhage in about 80% or more if it is performed expertly. Endoscopy should be done with in 48 hours of bleeding because it it is delayed, erosions may be healed and ulcer may lose the features like black base or adherent clot which enables the observer to pin point them as bleeding sources. In Bangladesh endoscopy is now available in almost every medical college hospitals and many diagnostic centers. So patients with upper GI hemorrhage are evaluated easily.

pper gastrointestinal (GI) bleeding represents a substantial clinical and economic burden. It has a prevalence of approximately 170 cases per 100 000 adults per year (1), at an estimated total cost of $750 million in U.S. dollars (2). Peptic ulcer disease accounts for 50% to 70% of cases of acute nonvariceal upper GI bleeding (3, 4). Despite recent advances in therapy, mortality rates have remained essentially unchanged at 6% to 8% (1, 2, 5). This could be explained by the fact that patients are older and have more concurrent illnesses; it may also be due to underuse of endoscopic hemostatic techniques. The Canadian Registry in Upper Gastrointestinal Bleeding and Endoscopy (RUGBE) initiative and international data have demonstrated wide variations in the utilization and timing of different diagnostic and therapeutic technologies, as well as disparate management approaches (4 10). In this context, it is surprising that, except for the recent British Society of Gastroenterology guidelines (9), the last widely disseminated consensus conference and

publication of practice guidelines occurred more than 10 years ago (11, 12). Since publication of the British Society of Gastroenterology guidelines, new data have become available and are strengthened by a series of evidence-based systematic reviews and meta-analyses performed for this consensus (13, 14). The current guidelines are a consensus paper with multisociety representation

INTRODUCTION
Acute upper gastrointestinal (GI) bleeding is a common cause of emergency hospitalisation worldwide.13 While considerable advances in the prevention of peptic ulcer complications have meant that the incidence of acute nonvariceal upper GI bleeding (NVUGIB) has decreased substantially in the past decade,4, 5 NVUGIB is still associated with considerable morbidity and mortality. Studies from North America, Europe and Asia most commonly place the incidence of continued and or re-bleeding and mortality following acute NVUGIB between 2% and 17%. 612 Recent data from randomised, controlled trials and metaanalyses have shown that appropriate endoscopic and pharmacological treatments can reduce the incidence of re-bleeding6, 11, 13, 14 and surgery,14 duration of hospitalisation13, 15 and number of blood units transfused.13, 15 However, mortality associated with the bleeding event seems to be much more difficult to improve.13, 14 For example, in a population-based study of patients hospitalised due to GI complications in Spain, the age- and genderadjusted mortality rate associated with upper GI bleeding events decreased between 1996 and 2005, but the case fatality rate has remained unchanged over this time period.16 The reasons for this remain unclear, but progressive population ageing and increased frequency of comorbidities may be relevant. Furthermore, the outcomes of NVUGIB, and factors associated with these outcomes in clinical practice, may be very different from those reported in randomised clinical trials. Also, factors unrelated to endoscopic and pharmacological treatments, such as organisational factors, early endoscopy, specialty-based management, and the use of predetermined care protocols may have a major impact on clinical outcomes. To further improve the management of NVUGIB, precise information regarding these issues is needed in clinical practice. The aim of the European Survey of Nonvariceal Upper Gastrointestinal Bleeding (ENERGIB) was to report on outcomes across different countries and evaluate a number of variables possibly associated with outcomes of acute NVUGIB including clinical predictors, management strategies and healthcare resource utilisation in a real-world, European, clinical practice setting. This report focuses on the predictors of poor outcomes of NVUGIB in terms of bleeding continuation re-bleeding and mortality.

Upper gastrointestinal bleeding (UGIB) is a common, potentially lifethreatening condition responsible for more than 300,000 hospital admissions and about 30,000 deaths per annum in America [1]. Treating and preventing UGIB costs many billions of dollars per annum [2]. Accurate patient evaluation and appropriate early management before esophagogastroduodenoscopy (EGD) is critical to decrease the morbidity and mortality. The early management focuses on resuscitative measures of fluid infusion or blood transfusion to reverse the direct consequences of bleeding; prevention of end-organ damage induced by the bleeding, such as hypoxia or prerenal azotemia; and general measures to promote hemostasis before EGD. Clinicians dwhether internists, intensivists, gastroenterologists, or gastrointestinal surgeonsdhave to be familiar with the initial evaluation and therapy to form a knowledgeable and cohesive team. This article focuses on the initial assessment, early resuscitative measures, and general therapy of UGIB before EGD, with a focus on new techniques, to optimize the patient therapy and thereby decrease patient morbidity and mortality. Epidemiology