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Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding is a common and potentially life-threatening condition among the elderly. The yearly incidence of upper gastrointestinal bleeding requiring hospitalization to be about 100 in 100,000 adults. This translates into 250,000 to 350,000 hospitalizations every year in the United States for acute upper gastrointestinal bleeding.

The incidence of upper gastrointestinal bleeding is twice as high in men as in women. Also, the incidence increases markedly with age: A 20-fold to 30-fold increase in incidence.

Outcome

Despite recent advances in management of upper gastrointestinal bleeding, poor outcomes remain common. Mortality rates from 2% to 15% have been reported recently.

The morbidity associated with upper gastrointestinal bleeding is substantial. Persistent or recurrent bleeding occurs in 5% to 30% of patients. Incidence is influenced by age, clinical severity of bleeding.

For diagnosis

Early endoscopy is the most accurate method available for identifying the site and source of bleeding. The frequency of the lesions detected depends, in part, on the population of patients studied, but in every reported series, peptic ulcer disease is most common (table 2).

Sources of Upper GI Bleeding
Diagnosis % of total diagnoses

(n = 258)*

% of total diagnoses (n = 195)
Duodenal ulcer 37.7:1 30.8
Gastric ulcer 24.0 19.0
Varices 6.2 10.8
Gastritis, duodenitis 10.5 5.6
Esophagitis, esophageal ulcer 5.5 10.3
Mallory-Weiss tear 3.5 7.2
Malignant lesion 1.6 4.6
Dieulafoy's lesion 1.2 1.0
Vascular ectasia 0.4 2.6
Other 1.6 1.0
Unknown or endoscopy not performed 8.1 7.2
 

For therapy

Endoscopic therapy has been shown to improve outcomes in patients with nonvariceal hemorrhage. In a recent meta-analysis of 30 randomized trials involving more than 2,000 patients, endoscopic therapy reduced rates of further bleeding (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.32.

The three chief methods of endoscopic therapy are: (1) thermal contact methods (heater probe, multipolar electrocoagulation), in which the bleeding vessel is compressed with a probe, which then heats the tissues, re-suiting in coagulation; (2) injection of the bleeding site with dilute epinephrine.

The endoscopic approach to lesions with an adherent clot but no active bleeding is the topic of much ongoing research. Currently, the most common approach is to attempt to displace the clot.

The rate of further bleeding in patients with active bleeding or nonbleeding visible vessels is reduced by about 50% with endoscopic therapy. However, in about 20% of such patients, bleeding persists.