upper gastrointestinal bleeding is one of the most common emergencies managed by gastroenterologists that results in high patient morbidity and medical care costs ( 1 ) . the main sources of upper gastrointestinal bleeding are peptic ulcers , esophagitis , drug - induced mucosal damage , sequelae of portal hypertension ( esophageal varices , varices of the gastric fundus , portal hypertensive gastropathy ) , vascular anomalies , traumatic and postoperative lesions , and tumors ( 3 ) . more recent data suggest that the proportion of cases caused by peptic ulcer disease has declined ( 4 , 5 , 7 ) . peptic ulcers were responsible for only 21 percent of episodes of upper gastrointestinal bleeding among 7822 patients included in a national , united states database between 1999 and 2001 . patients with variceal bleeding were excluded from the analysis ( 6 ) . in the present study all kinds of duodenal and gastric ulcers were treated as a single entity - peptic ulcers . every patient with peptic ulcer should already be tested for h.pylori at the initial endoscopy with rapid urease test and pathologic exam ( giemsa staining for helicobacter pylori ) . peptic ulcer as one of the most important reasons leading to upper gastrointestinal bleeding are mainly resulting from h.pylori infection or inappropriate and progressive use of nonsteroidal antiinflammatory drugs ( nsaids ) , stress in hospitalized patients and gastric acid and pepsin ( 9 , 10 ) . although helicobacter pylori infection is prevalent in developing countries , recent reports from different parts of asia have shown a declining trend for h. pylori - associated ulcers ( 11 , 12 ) . since h. pylori - negative ulcers have been shown to have a higher incidence of mortality and recurrent bleeding , documenting the proportion of such cases is important ( 13 ) . therefore more new studies are required to show recent changes in the incidence of various causes resulting in upper gastrointestinal bleeding . the number and the proportion of patients with non- h.pylori , non - nsaids peptic ulcer disease is important , given the increase in use of eradication therapy for h. pylori and widespread use of acid suppressor agents accompanied by nsaids ( 26 ) . in response to recent changes in the incidence of various causes of upper gastrointestinal bleeding and peptic ulcer diseases , the present study aimed to determine the proportion and actual numbers of patients with various causes of upper gastrointestinal bleeding , referred to the emergency room of taleghani hospital from january 2010 till december 2010 with a diagnosis of upper gastrointestinal bleeding and also the proportion and actual numbers of non - nsaid , non - helicobacter pylori peptic ulcers seen in endoscopy of these patients . this was a descriptive study conducted retrospectively on 157 medical records of patients admitted with a diagnosis of upper gastrointestinal bleeding referred to taleghani hospital . medical records of patients referred to the emergency room of taleghani hospital from january the first 2010 till december the 29th 2010 with a diagnosis of upper gastrointestinal bleeding in the form of hematemesis ( regurgitation or vomiting of blood ) , coffee ground material in nasogastric tube or melena ( black tarry stool with positive occult blood test ) were included in this study . patients with hematochezia ( passage of bright red blood per rectum ) with evidence of a source of bleeding from upper gastrointestinal tract in endoscopy were also included in this study . occasionally , the only finding pointing to a gastrointestinal hemorrhage is a laboratory result , such as iron - deficiency anemia or a positive test for occult blood in the stool with or without subjective signs such as fatigue , pallor , dyspepsia and etc . these patients were not enrolled in our study because our study focused on patients referred to emergency room . 21 patients were excluded from study ; 15 patients were referred with melena but with evidence of proximal lower gastrointestinal bleeding and no evidence of upper gastrointestinal bleeding in endoscopy , 4 patients did not consent to follow up with endoscopy and 2 patients had a diagnosis of hemoptysis and blood swallowing due to epistaxis respectively . therefore , care was taken not to enter patients with bleeding from upper respiratory tract or paranasal sinuses and lower gastrointestinal tract in this study . the mean age of patients was 55.9 years old with range of 15 - 89 years . after enrolment in the study , a questionnaire including demographic data , important points in the history , history of acid peptic disease , nsaid use , regular ingestion of aspirin , anticoagulants and other drugs can cause gastrointestinal bleeding eg , bisphosphonates , previous history of upper gastrointestinal bleeding and the cause of it , co - morbidities , physical exam such as ongoing vital signs , pallor , organomegaly , ascites , jaundice , laboratory tests such as ongoing bleeding , admission hemoglobin ( hgb ) , activated prothrombin time ( pt ) , platelet count ( plt ) , partial thromboplastin time ( ptt ) , and the results of endoscopy and etc was filled . also , mortality rate and re - bleeding in hospital and within 3 days after admission , blood transfusion need and surgery were registered . a hundred and thirty six patients entered the study , of which 51 ( 37.5% ) were female and 85 ( 62.5% ) were male . the most common signs on presentation among our patients were hematemesis and coffee ground vomiting ( 35% ) and melena ( 69% ) . they had shock ( blood pressure < 90/60 mmhg in supine position ) or orthostatic hypotension ( > 20 mmhg decrease in systolic blood pressure or > 10mmhg in diastolic blood pressure from supine to standing position ) . the incidence of patients with coagulopathy ( prolonged prothrombin or thromboplastin time compared with standard rates or low platelet levels < 150000 ) was 25% . the incidence of patients referred with comorbidities such as cirrhosis , diabetes , kidney stones , chronic renal failure , pancreatitis , chronic obstructive pulmonary disease , coronary artery disease , malignancies of the upper gastrointestinal tract was 39.7% . the frequency and incidence of patients referred with different comorbidities are shown in table 1 . comorbidities seen in study population ( n = 136 ) note that it was probable to see more than one comorbidity in one patient . sixty percent of patients gave a history of acid - peptic disease before presentation with upper gastrointestinal bleeding . thirty six percent of patients required emergent endoscopic intervention such as band ligation or sclerotherapy and 6.6% of patients required urgent surgery . during 3-day follow up of patients , 14 patients , ( 10.29% ) died . there was a significant relationship between death and existence of comorbidities ( p = 0.02 ) and unstable hemodynamic on arrival ( p = 0.01 ) . frequency and incidence of abnormalities seen in endoscopy of these patients referred to taleghani hospital with the impression of upper gastrointestinal bleeding are shown in table 2 . frequency and incidence of abnormalities seen in endoscopy of study population ( n = 136 ) abnormalities responsible for recent upper gastrointestinal bleeding in patients referred to taleghani hospital with upper gi bleeding are shown in table 3 . abnormalities responsible for recent upper gastrointestinal bleeding in study population ( n = 136 ) normal endoscopies could be due to subtle abnormalities , such as dieulafoy 's lesions , that can be missed easily during endoscopy . further studies are required to find out the real reason of upper gastrointestinal bleeding in these patients because normal results may be due to a careless endoscopy . in this study , peptic ulcer disease ( all kinds of ulcers such as ulcers with simple clot , with oozing from ulcer bed , with adherent clot , with visible vessels , and with spurting artery in stomach and duodenum were calculated as duodenal and gastric ulcers ) was seen in 61 patients ( 5 patients had the both duodenal and gastric ulcers ) . incidence of different drugs used in patients referred to the emergency room of taleghani hospital with upper gastrointestinal bleeding is shown in table 4 . incidence of different drugs used by study population only 47 of these ulcers were source of recent bleeding in these patients . multiple biopsies were taken and be sent to laboratory for rapid urease test and pathologic exam ( giemsa staining for h.pylori ) . 11.47% of patients had ulcers associated with both reasons ( h.pylori and consumption of nsaids ) . the frequency and incidence of peptic ulcers related and not related to h.pylori and nsaids are shown in table 5 . different kinds peptic ulcer disease in study population ( n = 61 ) the relationship between different causes of peptic ulcer disease ( helicobacter pylori related , nsaid use related , both helicobacter pylori and nsaid use related , no - nsaid no - helicobacter pylori related ) and existence of comorbidities is shown in table 6 . 
  the relationship between different causes of peptic ulcer disease and existence of comorbidities there was no significant relationship between existence of comorbidities and peptic ulcers related to h.pylori , nsaid use , both h.pylori and nsaid use . ( p = 0.734 , p = 0.598 , and p = 0.536 respectively ) but there was a significant relationship between existence of comorbidities and no - nsaid no - helicobacter pylori peptic ulcers . in this study , peptic ulcer disease was seen in 61 patients , 45% of abnormalities seen at the endoscopy of patients referred to taleghani hospital with a diagnosis of acute upper gastrointestinal bleeding . only 47 of these ulcers were source of recent bleeding in these patients . 11.47% of patients had ulcers associated with both reasons ( h.pylori and consumption of nsaids ) . there was no significant relationship between existence of comorbidities and peptic ulcers related to h.pylori , nsaids use , both helicobacter pylori and nsaids use . ( p = 0.734 , p = 0.598 , and p = 0.536 respectively ) but there was a significant relationship between existence of comorbidities and non - nsaids non- h.pylori peptic ulcers ( p = 0.035 ) . there was no significant relationship between age and different kinds of ulcers . according to the study of chow dk et al , non - nsaid non-h.pylori ulcer disease , that was believed to account for a minority of bleeding gastroduodenal ulcers , has been increasingly recognized for the past decade . their study suggests that both relative proportion and actual numbers of patients with non - nsaids and non-h.pylori ulcers have increased , whereas the prevalence of h.pylori -positive ulcers have declined . they made evidence to support non - nsaid non- h.pylori ulcers are associated with a higher risk of recurrent ulcer bleeding and a higher overall mortality as compared to h. pylori - positive ulcer disease . patients with non - nsaids non-h.pylori ulcers are often older , sicker and more frequently experience bleeding episodes while in hospital ( 29 ) . the results are in agreement with chow dk et al . the proportion of non - nsaids non - h . pylori has been increased recently because of a decline in the proportion of ulcers related to helicobacter pylori and nsaidsthe pathogenesis of non - nsaids non- h.pylori ulcer is largely unknown . more studies are necessary to discuss about causes resulting in non - nsaids non - helicobacter pylori ulcers to justify the increase in the actual number of these ulcers in recent studies . the results of this study supports the results of study done by yakoob j et al . that suggests the incidence of h.pylori infection related with duodenal ulcer is common , and in the presence of co - morbidities , non-h.pylori and non - nsaids duodenal ulcers are likely to be present ( 24 ) . in our study there was a significant relationship between comorbidities and non - nsaids , non- h.pylori peptic ulcers ( p = 0.035 ) , but there was no significant relationship between non - nsaids , non- h.pylori ulcers and the age of patients .