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Upper Gastrointestinal Bleeding

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Geriatric Gastroenterology

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Abstract

Upper gastrointestinal bleeding is a common reason for hospital admission in older adult patients and carries a high morbidity and mortality if not properly managed. Risk factors for developing upper GI bleeding include advanced age, H pylori infection, medication use (NSAIDs, Aspirin, P2Y12 inhibitors, anticoagulants, and steroids), smoking, and history of liver disease. Providers caring for older adults should try to minimize all modifiable risk factors for upper GI bleeding including reducing use of aspirin and NSAIDs (whenever possible) as well as coprescribing PPIs in patients who will be initiated on long-term NSAID therapy. The most common etiology of upper GI bleeding is peptic ulcer disease, followed by erosive gastroesophagitis, gastroesophageal varices, Mallory-Weiss tears, Dieulafoy’s lesions, gastric antral vascular ectasia (GAVE), portal hypertensive gastropathy (PHG), aortoenteric fistula, malignancy, and other rare conditions.

Early recognition and management of upper GI bleeding in adult patients is imperative and can potentially be lifesaving. A detailed history regarding prior history of upper GI bleeding, peptic ulcer disease, NSAIDs or anticoagulant use, and liver disease is vital. Common symptoms of upper GI bleeding include melena, hematemesis, nausea, and abdominal pain. Management begins with assessment of airway protection (and intubation if indicated), placement of two large bore IVs, administration of isotonic crystalloid solution and/or blood products, and administration of IV PPI. Patients with known or suspected liver disease and suspected variceal bleeding should also receive IV antibiotics and IV somatostatin analogs. Risk stratification scores should be used to determine patients at highest risk for further decompensation. Upper endoscopy is both a diagnostic and therapeutic tool used in the management of upper GI bleeding. Endoscopy should be performed within 24 h of presentation after appropriate resuscitation. Management of anticoagulation in upper GI bleeding largely depends on the indication for anticoagulation, the risk of continued bleeding with continuing the medication, and the risk of thrombosis with discontinuing the medication. A multidisciplinary approach to the decision of anticoagulation continuation is preferred when possible.

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References

  • Abbas AE, et al. Incidence and prognostic impact of gastrointestinal bleeding after percutaneous coronary intervention for acute myocardial infarction. Am J Cardiol. 2005;96(2):173–6.

    Article  PubMed  Google Scholar 

  • Abraham NS, et al. Gastrointestinal safety of direct oral anticoagulants: a large population-based study. Gastroenterology. 2017;152(5):1014–22.

    Article  CAS  PubMed  Google Scholar 

  • Acosta RD, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83(1):3–16.

    Article  PubMed  Google Scholar 

  • Al-Mallah M, et al. Predictors and outcomes associated with gastrointestinal bleeding in patients with acute coronary syndromes. J Thromb Thrombolysis. 2007;23(1):51–5.

    Article  PubMed  Google Scholar 

  • Barkun A, Leontiadis G. Systematic review of the symptom burden, quality of life impairment and costs associated with peptic ulcer disease. Am J Med. 2010;123(4):358–66.

    Article  PubMed  Google Scholar 

  • Bhatt DL, et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation task force on clinical expert consensus documents. J Am Coll Cardiol. 2008;52(18):1502–17.

    Article  PubMed  Google Scholar 

  • Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper gastrointestinal haemorrhage. Lancet. 2000;356(9238):1318–21.

    Article  CAS  PubMed  Google Scholar 

  • Bombardier C, et al. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N Engl J Med. 2000;343(21):1520–8.

    Article  CAS  PubMed  Google Scholar 

  • Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Med Clin N Am. 2008;92(3):491–509.

    Article  PubMed  Google Scholar 

  • Cave DR. Transmission and epidemiology of helicobacter pylori. Am J Med. 1996;100:12S–8S.

    Article  CAS  PubMed  Google Scholar 

  • Chait MM. Gastroesophageal reflux disease: important considerations for the older patients. World J Gastrointest Endosc. 2010;2(12):388.

    Article  PubMed  PubMed Central  Google Scholar 

  • Chavez-Tapia NC, et al. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding–an updated Cochrane review. Aliment Pharmacol Ther. 2011;34(5):509–18.

    Article  CAS  PubMed  Google Scholar 

  • Chen W-C, et al. Gastrointestinal hemorrhage in warfarin anticoagulated patients: incidence, risk factor, management, and outcome. Bio Med Res Int. 2014;2014

    Google Scholar 

  • Chey WD, et al. ACG clinical guideline: treatment of helicobacter pylori infection. Am J Gastroenterol. 2017;112(2):212–39.

    Article  PubMed  Google Scholar 

  • Connolly SJ, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139–51.

    Article  CAS  PubMed  Google Scholar 

  • Connolly SJ, et al. Full study report of andexanet alfa for bleeding associated with factor Xa inhibitors. N Engl J Med. 2019;380(14):1326–35.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Crowe, S. E., M. Feldman, and C. H. Ginsburg. Indications and diagnostic tests for Helicobacter pylori infection. Uptodate. Wellesley (2010);17(3).

    Google Scholar 

  • Cullen D, et al. Primary gastroduodenal prophylaxis with omeprazole for non-steroidal anti-inflammatory drug users. Aliment Pharmacol Ther. 1998;12(2):135–40.

    Article  CAS  PubMed  Google Scholar 

  • Dai C, et al. Endoscopic variceal ligation compared with endoscopic injection sclerotherapy for treatment of esophageal variceal hemorrhage: a meta-analysis. World J Gastroenterol: WJG. 2015;21(8):2534.

    Article  PubMed  PubMed Central  Google Scholar 

  • De Groen PC, et al. Esophagitis associated with the use of alendronate. N Engl J Med. 1996;335(14):1016–21.

    Article  PubMed  Google Scholar 

  • Doherty, John U., et al. 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol 69(7): 2017 871–898.

    Google Scholar 

  • Douketis JD, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. New Engl J Med. 2015;373(9):823–33.

    Article  CAS  PubMed  Google Scholar 

  • Fernández J, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology. 2006;131(4):1049–56.

    Article  PubMed  CAS  Google Scholar 

  • Foutch PG. Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol. 1993;88:6.

    Google Scholar 

  • Garcia DA, et al. Risk of thromboembolism with short-term interruption of warfarin therapy. Arch Intern Med. 2008;168(1):63–9.

    Article  CAS  PubMed  Google Scholar 

  • García-Pagán J-C, Gracia-Sancho J, Bosch J. Functional aspects on the pathophysiology of portal hypertension in cirrhosis. J Hepatol. 2012;57(2):458–61.

    Article  PubMed  Google Scholar 

  • Garcia-Tsao G, et al. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American association for the study of liver diseases. Hepatology. 2017;65(1):310–35.

    Article  PubMed  Google Scholar 

  • Garg SK, et al. Early esophagogastroduodenoscopy is associated with better outcomes in upper gastrointestinal bleeding: a nationwide study. Endosc Int Open. 2017;5(05):E376–86.

    Article  PubMed  PubMed Central  Google Scholar 

  • Gaziano JM, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet. 2018;392(10152):1036–46.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Gerson LB, et al. ACG clinical guideline: diagnosis and management of small bowel bleeding. Am J Gastroenterol. 2015;110(9):1265–87.

    Article  CAS  PubMed  Google Scholar 

  • Granger CB, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981–92.

    Article  CAS  PubMed  Google Scholar 

  • Green FW, et al. Effect of acid and pepsin on blood coagulation and platelet aggregation: a possible contributor to prolonged gastroduodenal mucosal hemorrhage. Gastroenterology. 1978;74(1):38–43.

    Article  CAS  PubMed  Google Scholar 

  • Guntipalli P, et al. Upper gastrointestinal bleeding caused by severe esophagitis: a unique clinical syndrome. Dig Dis Sci. 2014;59(12):2997–3003.

    Article  PubMed  Google Scholar 

  • Guo C-G, et al. Systematic review with meta-analysis: the risk of gastrointestinal bleeding in patients taking third-generation P2Y12 inhibitors compared with clopidogrel. Aliment Pharmacol Ther. 2019;49(1):7–19.

    Article  CAS  PubMed  Google Scholar 

  • Harris JM, DiPalma JA. Clinical significance of Mallory-Weiss tears. Am J Gastroenterol. 1993;88:12.

    Google Scholar 

  • Hooper L, et al. The effectiveness of five strategies for the prevention of gastrointestinal toxicity induced by non-steroidal anti-inflammatory drugs: systematic review. BMJ. 2004;329(7472):948.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Huang ES, et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc. 2011;74(5):971–80.

    Article  PubMed  Google Scholar 

  • January CT, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association task force on practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):e1–e76.

    Article  PubMed  Google Scholar 

  • Kaplan RC, Heckbert SR, Koepsell TD, Furberg CD, Polak JF. Risk factors for gastrointestinal bleeding among older patients. Cardiovascular health study investigators. J Am Geriatr Soc. 2001;49(2):126–33.

    Article  CAS  PubMed  Google Scholar 

  • Kaviani MJ, et al. Effect of oral omeprazole in reducing re-bleeding in bleeding peptic ulcers: a prospective, double-blind, randomized, clinical trial. Aliment Pharmacol Ther. 2003;17(2):211–6.

    Article  CAS  PubMed  Google Scholar 

  • Kumar NL, et al. Timing of upper endoscopy influences outcomes in patients with acute nonvariceal upper GI bleeding. Gastrointest Endosc. 2017;85(5):945–52.

    Article  PubMed  Google Scholar 

  • Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345–60.

    Article  CAS  PubMed  Google Scholar 

  • Laine L, et al. Effect of proton-pump inhibitor therapy on diagnostic testing for helicobacter pylori. Ann Intern Med. 1998;129(7):547–50.

    Article  CAS  PubMed  Google Scholar 

  • Leontiadis GI, Sharma VK, Howden CW. Systematic review and meta-analysis of proton pump inhibitor therapy in peptic ulcer bleeding. BMJ. 2005a;330(7491):568.

    Article  PubMed  PubMed Central  Google Scholar 

  • Leontiadis GI, Sharma VK, Howden CW. Systematic review and meta-analysis of proton pump inhibitor therapy in peptic ulcer bleeding. BMJ. 2005b;330(7491):568.

    Article  PubMed  PubMed Central  Google Scholar 

  • Leung PS, editor. The gastrointestinal system: gastrointestinal, nutritional and hepatobiliary physiology: Springer Science & Business; 2014.

    Google Scholar 

  • Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population–based study. Am J Gastroenterol. 1995;90:2.

    Google Scholar 

  • Lutz J, Jurk K, Schinzel H. Direct oral anticoagulants in patients with chronic kidney disease: patient selection and special considerations. Int J Nephrol Renov Dis. 2017;10:135.

    Article  CAS  Google Scholar 

  • Mallory GK. Hemorrhages from lacerations of the cardiac orifice of stomach due to vomiting. Am J Med Sci. 1929;178:506–15.

    Article  Google Scholar 

  • McNeil JJ, et al. Effect of aspirin on disability-free survival in the healthy elderly. N Engl J Med. 2018;379(16):1499–508.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. N Engl J Med. 1988;319(15):983–9.

    Article  Google Scholar 

  • O’Brien CW, Juraschek SP, Wee CC. Prevalence of aspirin use for primary prevention of cardiovascular disease in the United States: results from the 2017 National Health Interview Survey. Ann Intern Med. 2019;

    Google Scholar 

  • O’Mara C, Imbembo AL. Paraprosthetic-enteric fistula. Surgery. 1977;81(5):556–66.

    PubMed  Google Scholar 

  • Patel MR, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365(10):883–91.

    Article  CAS  PubMed  Google Scholar 

  • Pollack Charles V Jr, et al. Idarucizumab for dabigatran reversal – full cohort analysis. N Engl J Med. 2017;377(5):431–41.

    Article  PubMed  Google Scholar 

  • Pounder RE, Ng D. The prevalence of helicobacter pylori infection in different countries. Aliment Pharmacol Ther. 1995;9:33–9.

    PubMed  Google Scholar 

  • Rahman R, et al. Pre-endoscopic erythromycin administration in upper gastrointestinal bleeding: an updated meta-analysis and systematic review. Ann Gastroenterol. 2016;29(3):312.

    PubMed  PubMed Central  Google Scholar 

  • Raskin JB, et al. Misoprostol dosage in the prevention of nonsteroidal anti-inflammatory drug-induced gastric and duodenal ulcers: a comparison of three regimens. Ann Intern Med. 1995;123(5):344–50.

    Article  CAS  PubMed  Google Scholar 

  • Reddick AD, Ronald J, Morrison WG. Intravenous fluid resuscitation: was Poiseuille right? Emerg Med J. 2011;28(3):201–2.

    Article  PubMed  Google Scholar 

  • Rockall TA, et al. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. BMJ. 1995;311(6999):222–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Roudaut R, Serri K, Lafitte S. Thrombosis of prosthetic heart valves: diagnosis and therapeutic considerations. Heart. 2007;93(1):137–42.

    Article  PubMed  PubMed Central  Google Scholar 

  • Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(11):1755–62.

    Article  PubMed  PubMed Central  Google Scholar 

  • Saltzman JR, et al. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc. 2011;74(6):1215–24.

    Article  PubMed  Google Scholar 

  • Sanyal B. Methods to achieve hemostasis in patients with acute variceal hemorrhage: UpToDate; 2014.

    Google Scholar 

  • Srygley FD, et al. Does this patient have a severe upper gastrointestinal bleed? JAMA. 2012;307(10):1072–9.

    Article  CAS  PubMed  Google Scholar 

  • Stanley AJ, et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ. 2017;356:i6432.

    Article  PubMed  PubMed Central  Google Scholar 

  • Straus WL, Ofman JJ. Gastrointestinal toxicity associated with nonsteroidal anti-inflammatory drugs: epidemiologic and economic issues. Gastroenterol Clin. 2001;30(4):895–920.

    Article  CAS  Google Scholar 

  • Thiele M, et al. Meta-analysis: banding ligation and medical interventions for the prevention of rebleeding from oesophageal varices. Aliment Pharmacol Ther. 2012;35(10):1155–65.

    Article  CAS  PubMed  Google Scholar 

  • Vakil NB, Feldman M, Grover S. Peptic ulcer disease: clinical manifestations and diagnosis. UpToDate. 2016;2016

    Google Scholar 

  • Van Leerdam ME, et al. Acute upper GI bleeding: did anything change?: time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. Am J Gastroenterol. 2003;98(7):1494–9.

    Article  PubMed  Google Scholar 

  • Villanueva C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368(1):11–21.

    Article  CAS  PubMed  Google Scholar 

  • Wells M, et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther. 2012;35(11):1267–78.

    Article  CAS  PubMed  Google Scholar 

  • Wongrakpanich S, Wongrakpanich A, Melhado K, Rangaswami J. A comprehensive review of non-steroidal anti-inflammatory drug use in the elderly. Aging Dis. 2018;9(1):143.

    Article  PubMed  PubMed Central  Google Scholar 

  • Yoshiyama H, Nakazawa T. Unique mechanism of helicobacter pylori for colonizing the gastric mucus. Microbes Infect. 2000;2(1):55–60.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Nicholas J. Costable

  2. Department of Internal Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    David A. Greenwald

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  1. Nicholas J. Costable
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  2. David A. Greenwald
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Correspondence to David A. Greenwald .

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Editors and Affiliations

  1. Department of Medicine, Robert Wood Johnson School of Medicine, Rutgers University, New Brunswick, NJ, USA

    C. S. Pitchumoni

  2. Department of Medicine, Division of Geriatrics, Montefiore Medical Center, Wakefield Campus, Bronx, NY, USA

    T.S. Dharmarajan

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Costable, N.J., Greenwald, D.A. (2021). Upper Gastrointestinal Bleeding. In: Pitchumoni, C.S., Dharmarajan, T. (eds) Geriatric Gastroenterology. Springer, Cham. https://doi.org/10.1007/978-3-030-30192-7_47

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  • DOI: https://doi.org/10.1007/978-3-030-30192-7_47

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