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Gastrointestinal bleeding in the elderly is a common problem with numerous and varied causes. Its diagnosis and treatment require a careful, systematic approach by physicians with special expertise. Under the proper circumstances, elderly patients with upper or lower gastrointestinal bleeding do well even when surgery is required, and an individual's age, by itself, should not preclude aggressive medical care.
Upper gastrointestinal bleeding can be produced by varicose, inflammatory-ulcerative or neoplastic lesions of the eosophageal-gastric-duodenal anatomical district. The aim of this study was to define the role of arterial embolotherapy with an angiographic approach in the treatment of these conditions, starting from our personal experience and a review of the literature. The treatment of upper gastrointestinal bleeding is based on a multimodal approach in which arterial embolotherapy has its place alongside endoscopy and surgery.
OBJECTIVES: Cirrhotic patients with upper gastrointestinal bleeding are prone to bacterial infection. The aim of this study was to investigate the efficacy of prophylactic intestinal decontamination with oral ciprofloxacin for the prevention of bacterial infections in cirrhotic patients with upper gastrointestinal bleeding. METHODS: A total of 120 cirrhotic patients with acute upper gastrointestinal bleeding were enrolled. Sixty patients received ciprofloxacin 500 mg twice daily given orally or through nasogastric tube immediately after upper gastrointestinal endoscopic examination; drug administration continued for 7 days. The remaining 60 patients, who received placebo, served as controls. RESULTS: The incidence of proven bacterial infection in the ciprofloxacin-treated group was significantly lower than that of placebo group (10% vs 45%, p < 0.001). The incidences of bacteremia, spontaneous bacterial peritonitis, and urinary tract infection in the ciprofloxacin-treated group were significantly lower than those in the placebo group (0% vs 23%, 3.3% vs 13%, and 5% vs 18%, respectively; p < 0.05, respectively). Multivariate logistic regression analysis showed that a lack of prophylactic treatment with ciprofloxacin and severity of cirrhosis were the independent significant predictors for cirrhotic patients with acute gastrointestinal bleeding with infection. CONCLUSIONS: Prophylactic intestinal decontamination with oral ciprofloxacin is effective in the prevention of bacterial infections in patients with cirrhosis who were suffering from acute upper gastrointestinal hemorrhage.
Treatment of lower gastrointestinal bleeding was attempted in 13 patients by selective embolization of branches of the mesenteric arteries with Gelfoam. Bleeding was adequately controlled in 11 patients with active bleeding during the examination. One patient improved after embolization but bleeding recurred within 24 hours and in another patient the catheterization was unsuccessful. Five patients with diverticular hemorrhage were embolized in the right colic artery four times, and once in the middle colic artery. Three patients had embolization of the ileocolic artery because of hemorrhage from cecal angiodysplasia, post appendectomy, and leukemia infiltration. Three patients had the superior hemorrhoidal artery embolized because of bleeding from unspecific proctitis, infiltration of the rectum from a carcinoma of the bladder, and transendoscopic polypectomy. One patient was septic and bled from jejunal ulcers. Ischemic changes with infarction of the large bowel developed in two patients and were treated by partial semi-elective colectomy, three and four days after embolization. Four other patients developed pain and fever after embolization. Transcatheter embolization of branches of mesenteric arteries is an effective way to control acute lower gastrointestinal bleeding, but still has a significant rate of complications that must be seriously weighed against the advantages of operation.
Up to 5% of gastrointestinal bleeds occur between the ligament of Treitz and the ileocecal valve. These patients present with occult bleeding and pose diagnostic and therapeutic challenges. Currently, an array of technology exists for diagnostic purposes, including upper and lower endoscopies, capsule endoscopy, nuclear scans, angiography, and intraoperative endoscopy. All of these modalities have advantages and disadvantages. However, the diagnostic gold standard for occult gastrointestinal bleeding does not exist. We present a case of an 18-year-old male with occult gastrointestinal bleeding to illustrate the variety of available modalities. Initially, the patient underwent upper, lower, and push endoscopies. Subsequently, he had a nuclear bleeding scan, video capsule endoscopy, and an angiogram. Ultimately, the patient had a diagnostic laparoscopy with mobilization of the terminal ileum and right colon. The bowel was exteriorized and an intraoperative endoscopy was performed through a small bowel enterotomy. Multiple arteriovenous malformations (AVMs) were ascertained and resected. This case is presented in detail and the technique of intraoperative endscopy is reviewed. The diagnostic literature regarding AVMs is also reviewed.
Upper gastrointestinal hemorrhage, although accounting for more than 300,000 annual hospital admissions in the United States, continued to have about a 10% mortality rate over the past 50 years. Whether this is secondary to the increasing age of patients admitted with UGI hemorrhage, and their comorbid diseases, is unknown. The major approach to these patients includes volume and cardiovascular resuscitation, as well as surgical and gastroenterology consultation. Both clinical signs and endoscopic features in patients aid in predicting those at high risk of either rebleeding or dying, allowing for more aggressive steps, including endoscopic therapy of the bleeding site and surgery. Improved intensive care measures and endoscopic therapies for these patients may account for the signs of a recent decline in this mortality rate during the past 10 years.
BACKGROUND: A 15-fold increased risk of gastrointestinal bleeding has been reported with concurrent use of selective serotonin reuptake inhibitors and non-steroidal anti-inflammatory drugs. Recent guidance cautions against concurrent prescription, particularly in older people. AIM: To quantify the risk of gastrointestinal bleeding associated with current exposure to non-steroidal anti-inflammatory drugs, selective serotonin reuptake inhibitors, and both drugs concurrently. METHODS: We conducted a case-control analysis of 11,261 cases with upper gastrointestinal bleeding and 53,156 controls matched by gender, age and general practice from computerized primary care data. We coupled this with self-controlled case series analysis. RESULTS: Both drugs were associated with a twofold increased risk of gastrointestinal bleeding (odds ratio =2.38, 95% confidence interval 2.08-2.72 for selective serotonin reuptake inhibitors and odds ratio = 2.15, 95% confidence interval 2.02-2.28 for non-steroidal anti-inflammatory drugs). This increased risk was marginally higher for concurrent prescription (odds ratio = 2.93, 95% confidence interval 2.25-3.82). The self-controlled analysis showed a greater incidence rate ratio for gastrointestinal bleeding with non-steroidal anti-inflammatory drugs (2.71, 95% confidence interval 2.51-2.91) and lower incidence rate ratio with selective serotonin reuptake inhibitors (1.71, 95% confidence interval 1.48-1.98). The incidence rate ratio when both drugs were combined was 3.25, 95% confidence interval 1.95-5.42. Estimates were similar after restricting to people over 80 years of age. Increased risk of gastrointestinal bleeding was not specifically related to class of non-steroidal anti-inflammatory drugs and was similar when we looked at tricyclic anti-depressants. CONCLUSIONS: Our study suggests that the risk of gastrointestinal bleeding is not substantially increased when non-steroidal anti-inflammatory drugs and selective serotonin reuptake inhibitors are prescribed together, compared with their use alone.
OBJECTIVE: To review the management of acute gastrointestinal bleeding in the critically ill patient in a two part presentation. DATA SOURCES: Articles and a review of studies reported from 1991 to 2001 and identified through a MEDLINE search of the English language literature on acute gastrointestinal bleeding. SUMMARY OF REVIEW: Gastrointestinal bleeding is a relatively frequent problem in the critically ill patient. Common causes include acute stress ulceration (ASU), peptic ulceration and bleeding oesophageal varices. Non-variceal upper gastrointestinal bleeding requires resuscitation and correction of coagulation disturbances before endoscopy is performed. If a bleeding ulcer is detected it is often managed by an adrenaline injection or electrocautery into the base of the lesion and a proton pump inhibitor (e.g. omeprazole 80 mg i.v. followed by 8 mg/hr for 72 hr then 20 mg orally for 8 weeks). Surgery is considered for all patients in whom bleeding persists despite endoscopic or medical therapy. While H(2) receptor antagonists have been used for the management of ASU, proton pump inhibitors are currently prescribed due to their greater gastric acid suppressant effect (e.g. omeprazole 40 mg i.v. daily for ASU prophylaxis, 40 mg daily or 12-hourly for ASU with mild blood loss and 80 mg i.v. followed by 8 mg/hr for 72 hrs for ASU with severe haemorrhage). With severe haemorrhage, fibrinolytic inhibitors (e.g. tranexamic acid 3-6 g i.v. daily) may also be of benefit. For lower gastrointestinal bleeding or if there is no obvious upper gastrointestinal lesion during endoscopy, then selective mesenteric angiography with embolisation of the bleeding point (if the bleeding is brisk, e.g. > 0.5-2.0 mL/min) or colonoscopy with electrocautery or adrenaline injection (for diverticular haemorrhage) may be considered as an alternative to surgery. CONCLUSIONS: Acute upper gastrointestinal bleeding is often managed by intravenous proton pump inhibitors and endoscopy with electrocautery or adrenaline injection when a bleeding at the base of an ulcer is found. For lower gastrointestinal haemorrhage, selective mesenteric angiography with embolisation of the bleeding point is an alternative to surgery in critically ill patients. Fibrinolytic inhibitors may have added benefit.
Gastrointestinal hemorrhage in infants and children is a catastrophic event but is not associated with significant mortality except in those with a severe primary illness. Upper gastrointestinal bleeding in infants and young children is most often associated with stress ulcers or erosions, but in older children it may also be caused by duodenal ulcer, esophagitis, and esophageal varices. Lower gastrointestinal bleeding may be caused by a variety of lesions among which are infectious colitides, Meckel's diverticulum, bleeding disorders, gastrointestinal allergy, and inflammatory bowel disease. Techniques of diagnosis and management are discussed.
BACKGROUND: Upper gastrointestinal bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. Several treatments are used for upper gastrointestinal bleeding in patients with liver diseases. However, supplementary interventions are often used as well. One of them is vitamin K administration, but it is unknown whether it benefits or harms patients with liver disease and upper gastrointestinal bleeding. OBJECTIVES: To assess the beneficial and harmful effects of vitamin K for patients with liver disease and upper gastrointestinal bleeding. SEARCH STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (February 2004), which comprises references identified from comprehensive electronic database searches and handsearching of relevant journals and abstract books of conference proceedings, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to March 2004), EMBASE (1988 to March 2004), and LILACS (1982 to March 2004). Additional randomised trials were sought from the reference lists of the trials found and reviews identified by the electronic searches. SELECTION CRITERIA: We intended to include randomised clinical trials. DATA COLLECTION AND ANALYSIS: We intended to summarise data by standard Cochrane Collaboration methodologies. MAIN RESULTS: We could not find any randomised trials on vitamin K for upper gastrointestinal bleeding in patients with liver diseases. AUTHORS' CONCLUSIONS: We were unable to identify randomised trials on the safety and efficacy of vitamin K for upper gastrointestinal bleeding in patients with liver diseases. The effects of vitamin K need to be tested in randomised clinical trials.
OBJECTIVE: Gastrointestinal bleeding occurs in a number of patients with hereditary hemorrhagic telangiectasia (HHT) and may lead to a high transfusion need. The aim of this study was to estimate the occurrence and severity of gastrointestinal bleeding in a geographically well defined HHT population. METHODS: All HHT families in the county of Fyn, Denmark, (470,000 population) have been identified. Probands and their first degree relatives, and all descendants from probands for whom one parent had HHT were eligible for inclusion in the study. A total of 77 patients with HHT were identified; of these, 76 patients (mean age: 52 yr) were evaluated and interviewed with regard to gastrointestinal bleeding, that is, a history of either hematemesis or melena. Patients charts were reviewed. RESULTS: A total of 25 HHT patients (33%) had a history of either hematemesis or melena. Of these, 12 (48%) had received blood transfusions. Seven patients had severe bleeding (that is, > or =6 units of blood within 6 months before inclusion in the study). Endoscopy had been performed in 16 of the 25 (64%) patients. Telangiectatic lesions were documented in nine at upper endoscopy and in one at sigmoidoscopy. Telangiectatic lesions were observed in all patients with severe bleeding, but in two patients epistaxis is likely to have contributed to the anemia. Among 51 HHT patients without a history of gastrointestinal bleeding, only five (10%) had previously received blood transfusions; however, none fulfilled the definition of severe bleeding. In the HHT population 29 patients were > or =60 yr old, but all patients with severe bleeding were > or =60 yr. CONCLUSIONS: A history of gastrointestinal bleeding is common in patients with HHT (33%). This study documents that 25% of HHT patients > or =60 yr suffer from severe gastrointestinal bleeding.
UNLABELLED: This multicentered, placebo-controlled trial evaluated the efficacy of medical therapy to stop bleeding in 285 patients with active upper gastrointestinal bleeding (bleeding phase) and 194 patients who had ceased gastrointestinal bleeding and in whom therapy was instituted to prevent rebleeding during the same hospitalization (prevention phase). Patients in the bleeding phase were given cimetidine (300 mg every six hours) or intravenous placebo. There was no significant overall difference between intravenous cimetidine (71 percent) and placebo (77 percent) in stopping acute upper gastrointestinal bleeding. There was also no significant difference noted between intravenous cimetidine and placebo when specific bleeding lesions were evaluated. Once gastrointestinal bleeding had stopped, recurrence of bleeding while receiving prevention therapy (cimetidine tablets 300 mg one three times a day and at bedtime, or Mylanta II liquid 30 ml every hour, or cimetidine plus hourly antacids, or placebo) was evaluated in 194 of the patients in the bleeding phase. Twenty-four percent (12 of 51 patients) rebled while receiving cimetidine, 13 percent (five of 39 patients) rebled while receiving hourly antacids, 11 percent (six of 54 patients) rebled while receiving cimetidine plus hourly antacids, and 26 percent (13 of 50 patients) rebled while receiving placebo. None of these prevention regimens reached statistical significance (p = 0.13). Evaluation of specific bleeding lesions within this group also failed to show any significant value of prevention therapy. IN CONCLUSION: (1) intravenous cimetidine offers no advantage over placebo in stopping active upper gastrointestinal bleeding; (2) the occurrence of rebleeding during the same hospitalization does not appear to be significantly affected by any of the medical regimens used for prevention. These findings would suggest that the cessation of active bleeding and the prevention of recurrent upper gastrointestinal bleeding during a single hospitalization appear to be unaffected by therapy directed at acid neutralization or reduction.
Several recent advances have been made in the evaluation and management of acute lower gastrointestinal bleeding. This review focuses on the management of lower gastrointestinal bleeding, especially acute severe bleeding. The aim of the study was to critically review the published literature on important management issues in lower gastrointestinal bleeding, including haemodynamic resuscitation, diagnostic evaluation, and endoscopic, radiologic, and surgical therapy, and to develop an algorithm for the management of lower gastrointestinal bleeding, based on this literature review. Publications pertaining to lower gastrointestinal bleeding were identified by searches of the MEDLINE database for the years 1966 to December 2004. Clinical trials and review articles were specifically identified, and their reference citation lists were searched for additional publications not identified in the database searches. Clinical trials and current clinical recommendations were assessed by using commonly applied criteria. Specific recommendations are made based on the evidence reviewed. Approximately, 200 original and review articles were reviewed and graded. There is a paucity of high-quality evidence to guide the management of lower gastrointestinal bleeding, and current endoscopic, radiologic, and surgical practices appear to reflect local expertise and availability of services. Endoscopic literature supports the role of urgent colonoscopy and therapy where possible. Radiology literature supports the role of angiography, especially after a positive bleeding scan has been obtained. Limited surgical data support the role of segmental resection in the management of persistent lower gastrointestinal bleeding after localization by either colonoscopy or angiography. There is limited high-quality research in the area of lower gastrointestinal bleeding. Recent advances have improved the endoscopic, radiologic and surgical management of this problem. However, treatment decisions are still often based on local expertise and preference. With increased access to urgent therapeutic endoscopy for the management of acute upper gastrointestinal bleeding, diagnostic and therapeutic colonoscopy can be expected to play an increasing role in the management of acute lower gastrointestinal bleeding.
BACKGROUND AND STUDY AIMS: In cases of hookworm and roundworm infestation, chronic occult bleeding is well known, but acute gastrointestinal bleeding is rarely described. We report five patients with worm infestation who presented with acute massive gastrointestinal bleeding. PATIENTS AND METHODS: Over 1 year, we have encountered 15 patients with obscure gastrointestinal bleeding. All the patients had normal findings on upper gastrointestinal endoscopy. Push enteroscopy was performed in each patient and evaluation of the proximal 40-50 cm of the jejunum was done. RESULTS: Five patients (four men, one woman; average age 50 yr, range 40-60) had worm infestation (two hookworm, three roundworm). All the patients had gastrointestinal bleeding (five had melena, one hematemesis, and two hematochezia) for a duration of 7-14 days. Hemoglobin ranged from 2.8 to 9 g/dl. Push enteroscopy revealed fresh blood in the jejunum, multiple erosions, and hookworms in two patients and roundworms in three patients. Hookworms were retrieved endoscopically in two patients whereas roundworms could be retrieved in only one patient. All the patients were treated with mebendazole (100 mg twice a day for 3 days), iron, and folic acid. Gastrointestinal bleeding subsided in all the patients. CONCLUSIONS: In developing countries, worm infestation should be considered an important cause of obscure acute gastrointestinal bleeding. Evaluation of the jejunum using an enteroscope will result in more frequent diagnosis of worms as a cause of acute gastrointestinal bleeding which might have been classified as obscure gastrointestinal bleeding.
In 5% of patients with gastrointestinal bleeding, standard evaluation fails to reveal the source of the bleeding. We describe the management of 71 patients treated for obscure gastrointestinal bleeding at the Mount Sinai Medical Center, New York, New York, from 1985 to 1991. There were 38 men (54%) and 33 women (46%). The mean age was 60 years. The patients had bleeding episodes for a mean period of 26 months and required an average of 20 units of blood prior to surgical treatment. All had undergone an extensive diagnostic workup including barium contrast studies, endoscopies, and angiographies. Some had multiple bleeding scans, Meckel scans, and surgical explorations. Three patients were found to have "watermelon stomach" on endoscopy and had an antrectomy. Sixty-eight (96%) patients underwent a preoperative small bowel enteroscopy, which revealed the precise diagnosis in 50 (70%) of the patients. All patients underwent surgery. In 30 (42%) patients in whom the bleeding site was not apparent at exploration, intraoperative enteroscopy was performed. Two actively bleeding patients had intraoperative enteroscopy, which failed to localize the bleeding site, and intraoperative scintigraphy was utilized. The bleeding was found to originate in small bowel arteriovenous malformation (AVM) (28 patients), leiomyoma (8 patients), primary small bowel malignancies (11 patients), and other causes (24 patients). Fifty-six patients (80%) had no further bleeding; 9 with multiple small bowel AVM have experienced rebleeding and are alive. Six patients died of recurrent bleeding, and six died of metastatic cancer. An aggressive approach should be applied in patients in whom standard evaluation fails to localize the source of gastrointestinal bleeding. Enteroscopy, surgical exploration with additional intraoperative enteroscopy, and occasional intraoperative scintigraphy can achieve an excellent yield and allow resection and potential cure.
The seasonal fluctuations of acute upper gastrointestinal bleeding treated from 1991 to 1996 in Patras, Greece, were analyzed retrospectively. During that period, 1992 patients with acute upper gastrointestinal bleeding were admitted to our hospital. After patients who were not residents of the region served by our hospital were excluded, the remaining 1879 cases were reviewed. We observed seasonal fluctuation with low prevalence in winter and an increase in spring and autumn with two peaks in April and October (p < 0.00001). The seasonal prevalence parallels that of duodenal ulcer bleeding, which follows a similar fluctuation (p < 0.00001). Bleeding due to gastric ulcers or other causes presented no periodicity. Seasonal fluctuation, both in total numbers of upper gastrointestinal bleeding and in duodenal ulcer bleeding, was statistically significant only in patients not receiving nonsteroidal anti-inflammatory drugs (p < 0.00001). We conclude that upper gastrointestinal bleeding shows a seasonal fluctuation parallel to duodenal ulcer bleeding and is not related to nonsteroidal anti-inflammatory drugs. The seasonal pattern supports the traditional view of duodenal ulcer exacerbations.
Acute gastrointestinal bleeding, a common problem, becomes a serious situation in the 15% of afflicted patients in whom the bleeding does not stop spontaneously. The typical high-risk patient is elderly, has multisystem disease, has a hemorrhagic episode during hospitalization for other disorders, or is an outpatient with severe bleeding of short duration and symptoms of volume depletion. Endoscopy can be performed to identify the active site of hemorrhage and is associated with an overall diagnostic accuracy that exceeds 90% in patients with upper gastrointestinal bleeding. The rate and character of observed bleeding have substantial predictive value for continued bleeding. The mortality among high-risk patients with bleeding in either the upper or the lower gastrointestinal tract ranges from 17 to 44%. Therefore, an organized aggressive approach to management of acute gastrointestinal bleeding is necessary.
OBJECTIVES: Gastrointestinal bleeding and ulcers may lead to life-threatening complications. One of the causes is use of non-steroidal anti-inflammatory drugs (NSAIDs). METHODS: All hospital admissions in 1998 to the Departments of Internal Medicine, including the Intensive Care Unit and the Department of Surgery, in 2 hospitals in Rostock were prospectively screened for gastrointestinal bleeding. Whether the bleeding was due to an adverse drug reaction ADR or not was assessed using the rating scale of Begaud et al. [1985] for each drug taken. The risk profile and the drug history of all patients with gastrointestinal bleeding were registered. RESULTS: A total of 58 patients with gastrointestinal bleeding due to NSAIDs were documented. Risk factors for bleeding were cardiac diseases, hypertension, diabetes, age over 60 years, history of ulcer, a Helicobacter pylori infection, smoking and consumption of alcohol together with drugs known to have a risk of causing gastrointestinal bleeding and ulcers (antiplatelet drugs, anticoagulants, corticosteroids). About 70% of these patients had 3 or more risk factors, but only 20% had been receiving effective prophylaxis with a proton pump inhibitor. CONCLUSION: Gastrointestinal problems resulting from the use of NSAIDs are clinically important. It is concluded, that individual risk profiles, as a criterion for the prophylactic use of effective protective drugs, would be helpful in patients management.