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Upper and Lower Gastrointestinal Bleeding

  • Paola Fugazzola
  • Giulia Montori
  • Camilla Bing
  • Fausto Catena
  • Massimo Sartelli
  • Luca Ansaloni
  • Federico Coccolini
Chapter

Abstract

More than 1% of people aged 80 years and older are hospitalized each year because of gastrointestinal bleeding, and rates of both upper and lower GI hemorrhages increase significantly with aging. Gastrointestinal bleeding in such elderly people can originate from lesions common to all age groups or from lesions associated specifically with aging. Although the approach to the diagnosis and management of gastrointestinal bleeding is not specific to elderly people, elderly people differ from younger people in the same conditions for several aspects of clinical presentation and outcomes. In elderly people, morbidity and mortality from GI bleeding are determined by both the nature and the entity of bleeding and by the presence of comorbid medical conditions, including cardiovascular and pulmonary disease; furthermore, they are commonly prescribed numerous medications which may compromise mucosal integrity and predispose bleeding (aspirin, NSAID, anticoagulant, and antiplatelet medications). In this chapter, clinical presentation, etiology, risk factors, diagnostic tools, and management in upper and lower gastrointestinal bleeding are explained.

Keywords

Gastrointestinal hemorrhage Elderly Hematemesis Melena Peptic ulcer Diverticular hemorrhage 

References

  1. 1.
    Kaplan RC, et al. Risk factors for hospitalized gastrointestinal bleeding among older persons. J Am Geriatr Soc. 2001;49:126–33.CrossRefGoogle Scholar
  2. 2.
    Constantini TW, Kobayashi LM, Coimbra R. Intestinal hemorrhage in elderly. In: Yelon JA, Luchette FA, editors. Geriatric trauma e critical care. New York: Springer Science+Business Media; 2014. p. 145–54.CrossRefGoogle Scholar
  3. 3.
    Yachimski PS, Friedman LS. Gastrointestinal bleeding in the elderly. Nat Clin Pract Gastroenterol Hepatol. 2008;5(2):80–93.  https://doi.org/10.1038/ncpgasthep1034.CrossRefPubMedGoogle Scholar
  4. 4.
    Farrell JJ, Friedman LS. Gastrointestinal bleeding in older people. Gastroenterol Clin N Am. 2000;29:1–36.CrossRefGoogle Scholar
  5. 5.
    Nikolsky E, Mehran R, Stone GW. Gastrointestinal bleeding in percutaneous coronary intervention and acute coronary syndromes. Am J Cardiol. 2009;104(5 Suppl):22C–9.CrossRefGoogle Scholar
  6. 6.
    Hylek EM, Evans-Molina C, Shea C, Henault LE, Regan S. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation. 2007;115(21):2689–96.CrossRefGoogle Scholar
  7. 7.
    Wierzchowski P. Urgent endoscopy in elderly patients with non-variceal upper gastrointestinal bleeding. Videosurg Other Miniinvasive Tech. 2012;7(4):246–50.  https://doi.org/10.5114/wiitm.2011.28907.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Rockall TA, et al. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the national audit of acute upper gastrointestinal hemorrhage. BMJ. 1995;311:222–6.CrossRefGoogle Scholar
  9. 9.
    Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol. 1995;90:206–10.PubMedGoogle Scholar
  10. 10.
    Seinela L, Ahvenainen J. Peptic ulcer in the very old patients. Gerontology. 2000;46:271–5.CrossRefGoogle Scholar
  11. 11.
    Kemppainen H, Raiha I, Sourander L. Clinical presentation of peptic ulcer in the elderly. Gerontology. 1997;43:283–8.CrossRefGoogle Scholar
  12. 12.
    Pilotto A, Maggi S, Noale M, et al. Development and validation of a new questionnaire for the evaluation of upper gastrointestinal symptoms in the elderly population: a multicenter study. J Gerontol A Biol Sci Med Sci. 2010;65:174–8.CrossRefGoogle Scholar
  13. 13.
    Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol. 1997;92(3):419–24.PubMedGoogle Scholar
  14. 14.
    Higham J, Kang JY, Majeed A. Recent trends in admissions and mortality due to peptic ulcer in England: increasing frequency of haemorrhage among older subjects. Gut. 2002;50:460–4.CrossRefGoogle Scholar
  15. 15.
    Kyaw MH, Chan FK. Pharmacologic options in the management of upper gastrointestinal bleeding: focus on the elderly. Drugs Aging. 2014;31(5):349–61.CrossRefGoogle Scholar
  16. 16.
    Newton JL. Improving the gastrointestinal tolerability of aspirin in older people. Clin Interv Aging. 2006;1:33–9.CrossRefGoogle Scholar
  17. 17.
    Cryer B, Lee E, Feldman M. Factors influencing gastroduodenal mucosal prostaglandin concentrations: roles of smoking and aging. Ann Intern Med. 1992;116:636–40.CrossRefGoogle Scholar
  18. 18.
    Goto H, Sugiyama S, Ohara A, et al. Age-associated decreases in prostaglandin contents in human gastric mucosa. Biochem Biophys Res Commun. 1992;186:1443–8.CrossRefGoogle Scholar
  19. 19.
    Guslandi M, Pellegrini A, Sorghi M. Gastric mucosal defences in the elderly. Gerontology. 1999;45:206–8.CrossRefGoogle Scholar
  20. 20.
    Kim SW, Parekh D, Townsend CM Jr, et al. Effects of aging on duodenal bicarbonate secretion. Ann Surg. 1990;212:332–7; discussion 337–8CrossRefGoogle Scholar
  21. 21.
    Brogna A, Ferrara R, Bucceri AM, et al. Influence of aging on gastrointestinal transit time: an ultrasonographic and radiologic study. Investig Radiol. 1999;34:357–9.CrossRefGoogle Scholar
  22. 22.
    Scheiman JM, Yeomans ND, Talley NJ, et al. Prevention of ulcers by esomeprazole in at-risk patients using non-selective NSAIDs and COX-2 inhibitors. Am J Gastroenterol. 2006;101:701–10.CrossRefGoogle Scholar
  23. 23.
    Rostom A, Dube C, Wells G, et al. Prevention of NSAID-induced gastroduodenal ulcers. Cochrane Database Syst Rev. 2002;4:CD002296.Google Scholar
  24. 24.
    Yeomans ND, Tulassay Z, Juhasz L, et al. A comparison of omeprazole with ranitidine for ulcers associated with nonsteroidal antiinflammatory drugs: acid suppression trial: ranitidine versus omeprazole for NSAID-associated ulcer treatment (ASTRONAUT) study group. N Engl J Med. 1998;338:719–26.CrossRefGoogle Scholar
  25. 25.
    Ishihara M, Ito M. Influence of aging on gastric ulcer healing activities of cimetidine and omeprazole. Eur J Pharmacol. 2002;444:209–15.CrossRefGoogle Scholar
  26. 26.
    Maggio M, Corsonello A, Ceda GP, et al. Proton pump inhibitors and risk of 1-year mortality and rehospitalization in older patients discharged from acute care hospitals. JAMA Intern Med. 2013;173:518–23.CrossRefGoogle Scholar
  27. 27.
    Deshpande A, Pant C, Pasupuleti V, et al. Association between proton pump inhibitor therapy and Clostridium difficile infection in a meta-analysis. Clin Gastroenterol Hepatol. 2012;10:225–33.CrossRefGoogle Scholar
  28. 28.
    Johnstone J, Nerenberg K, Loeb M. Meta-analysis: proton pump inhibitor use and the risk of community-acquired pneumonia. Aliment Pharmacol Ther. 2010;31:1165–77.CrossRefGoogle Scholar
  29. 29.
    Ngamruengphong S, Leontiadis GI, Radhi S, et al. Proton pump inhibitors and risk of fracture: a systematic review and metaanalysis of observational studies. Am J Gastroenterol. 2011;106:1209–18; quiz 1219CrossRefGoogle Scholar
  30. 30.
    Ahmed A, Stanley AJ. Acute upper gastrointestinal bleeding in the elderly: aetiology, diagnosis and treatment. Drugs Aging. 2012;29(12):933–40.  https://doi.org/10.1007/s40266-012-0020-5.CrossRefPubMedGoogle Scholar
  31. 31.
    Hosking SW, et al. Management of bleeding varices in the elderly. BMJ. 1989;298:152–3.CrossRefGoogle Scholar
  32. 32.
    Bergqvist D, et al. Secondary aortoenteric fistulate—changes from 1973 to 1993. Eur J Endovasc Surg. 1996;11:425–8.CrossRefGoogle Scholar
  33. 33.
    Cendan JC, et al. Twenty-one cases of aortoenteric fistula: lessons for the general surgeon. Am Surg. 2004;70:583–7.PubMedGoogle Scholar
  34. 34.
    Rockall TA, Logan RFA, Devlin HB, et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut. 1996;38:316–21.CrossRefGoogle Scholar
  35. 35.
    Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment of upper gastrointestinal haemorrhage. Lancet. 2000;356:1318–21.CrossRefGoogle Scholar
  36. 36.
    Wang CY, Qin J, Wang J, Sun CY, Cao T, Zhu DD. Rockall score in predicting outcomes of elderly patients with acute upper gastrointestinal bleeding. World J Gastrointest Endosc. 2010;2(5):147–54.  https://doi.org/10.4253/wjge.v2.i5.147.38.CrossRefGoogle Scholar
  37. 37.
    Chait MM. Lower gastrointestinal bleeding in the elderly. World J Gastrointest Endosc. 2010;2(5):147–54.  https://doi.org/10.4253/wjge.v2.i5.147.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    McGuire HH Jr. Bleeding colonic diverticula. A reappraisal of natural history and management. Ann Surg. 1994;220(5):653–6.CrossRefGoogle Scholar
  39. 39.
    Comay D, Marshall JK. Resource utilization for acute lower gastrointestinal hemorrhage: the Ontario GI bleed study. Can J Gastroenterol. 2002;16:677–82.CrossRefGoogle Scholar
  40. 40.
    Ríos A, Montoya MJ, Rodríguez JM, Serrano A, Molina J, Parrilla P. Acute lower gastrointestinal hemorrhages in geriatric patients. Dig Dis Sci. 2005;50:898–904.CrossRefGoogle Scholar
  41. 41.
    Rockey DC. Lower gastrointestinal bleeding. Gastroenterology. 2006;130:165–71.CrossRefGoogle Scholar
  42. 42.
    Rhee JC, Lee KT. The causes and management of lower GI bleeding: a study based on clinical observations at Hanyang University Hospital. Gastroenterol Jpn. 1991;26(Suppl 3):101–6.PubMedGoogle Scholar
  43. 43.
    Bokhari M, Vernava AM, Ure T, Longo WE. Diverticular hemorrhage in the elderly—is it well tolerated? Dis Colon Rectum. 1996;39:191–5.CrossRefGoogle Scholar
  44. 44.
    Stollman N, Raskin JB. Diverticular disease of the colon. Lancet. 2004;363:631–9.CrossRefGoogle Scholar
  45. 45.
    Reinus JF, Brandt LJ. Vascular ectasias and diverticulosis. Common causes of lower intestinal bleeding. Gastroenterol Clin N Am. 1994;23:1–20.Google Scholar
  46. 46.
    Boley SJ, Sammartano R, Adams A, DiBiase A, Kleinhaus S, Sprayregen S. On the nature and etiology of vascular ectasias of the colon. Degenerative lesions of aging. Gastroenterology. 1977;72:650–60.PubMedGoogle Scholar
  47. 47.
    Imperiale TF, Ransohoff DF. Aortic stenosis, idiopathic gastrointestinal bleeding, and angiodysplasia: is there an association? A methodologic critique of the literature. Gastroenterology. 1988;95:1670–6.CrossRefGoogle Scholar
  48. 48.
    Lindner AE. Inflammatory bowel disease in the elderly. Clin Geriatr Med. 1999;15:487–97.PubMedGoogle Scholar
  49. 49.
    Robertson DJ, Grimm IS. Inflammatory bowel disease in the elderly. Gastroenterol Clin N Am. 2001;30:409–26.CrossRefGoogle Scholar
  50. 50.
    Robert JH, Sachar DB, Aufses AH Jr, Greenstein AJ. Management of severe hemorrhage in ulcerative colitis. Am J Surg. 1990;159:550–5.CrossRefGoogle Scholar
  51. 51.
    Medina C, Vilaseca J, Videla S, Fabra R, Armengol-Miro JR, Malagelada JR. Outcome of patients with ischemic colitis: review of fifty-three cases. Dis Colon Rectum. 2004;47:180–4.CrossRefGoogle Scholar
  52. 52.
    Lew JF, Glass RI, Gangarosa RE, Cohen IP, Bern C, Moe CL. Diarrheal deaths in the United States, 1979 through 1987. A special problem for the elderly. JAMA. 1991;265:3280–4.CrossRefGoogle Scholar
  53. 53.
    Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV, Hennessy T, Griffin PM, DuPont H, Sack RB, Tarr P, Neill M, Nachamkin I, Reller LB, Osterholm MT, Bennish ML, Pickering LK. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis. 2001;32:331–51.CrossRefGoogle Scholar
  54. 54.
    Slotwiner-Nie PK, Brandt LJ. Infectious diarrhea in the elderly. Gastroenterol Clin N Am. 2001;30:625–35.CrossRefGoogle Scholar
  55. 55.
    Peura DA, Lanza FL, Gostout CJ, Foutch PG. The American College of Gastroenterology bleeding registry: preliminary findings. Am J Gastroenterol. 1997;92:924–8.PubMedGoogle Scholar
  56. 56.
    Richter JM, Christensen MR, Kaplan LM, Nishioka NS. Effectiveness of current technology in the diagnosis and management of lower gastrointestinal hemorrhage. Gastrointest Endosc. 1995;41:93–8.CrossRefGoogle Scholar
  57. 57.
    Kim HS, Kim TI, Kim WH, Kim YH, Kim HJ, Yang SK, Myung SJ, Byeon JS, Lee MS, Chung IK, Jung SA, Jeen YT, Choi JH, Choi KY, Choi H, Han DS, Song JS. Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study. Am J Gastroenterol. 2006;101:1333–41.CrossRefGoogle Scholar
  58. 58.
    Mühldorfer SM, Kekos G, Hahn EG, Ell C. Complications of therapeutic gastrointestinal endoscopy. Endoscopy. 1992;24:276–83.CrossRefGoogle Scholar
  59. 59.
    Rex DK, Lewis BS, Waye JD. Colonoscopy and endoscopic therapy for delayed post-polypectomy hemorrhage. Gastrointest Endosc. 1992;38:127–9.CrossRefGoogle Scholar
  60. 60.
    Tseng CA, Chen LT, Tsai KB, Su YC, Wu DC, Jan CM, Wang WM, Pan YS. Acute hemorrhagic rectal ulcer syndrome: a new clinical entity? Report of 19 cases and review of the literature. Dis Colon Rectum. 2004;47:895–903; discussion 903–905CrossRefGoogle Scholar
  61. 61.
    Jafri SM, Monkemuller K, Lukens FJ. Endoscopy in the elderly: a review of the efficacy and safety of colonoscopy, esophagogastroduodenoscopy, and endoscopic retrograde cholangiopancreatography. J Clin Gastroenterol. 2010;44(3):161–6.CrossRefGoogle Scholar
  62. 62.
    Hilton D, Iman N, Burke GJ, Moore A, O’Mara G, Signorini D, Lyons D, Banerjee AK, Clinch D. Absence of abdominal pain in older persons with endoscopic ulcers: a prospective study. Am J Gastroenterol. 2001;96:380–4.CrossRefGoogle Scholar
  63. 63.
    Waye JD, Bashkoff E. Total colonoscopy: is it always possible? Gastrointest Endosc. 1991;37:152–4.CrossRefGoogle Scholar
  64. 64.
    Zuckerman DA, Bocchini TP, Birnbaum EH. Massive hemorrhage in the lower gastrointestinal tract in adults: diagnostic imaging and intervention. Am J Roentgenol. 1993;161:703–11.CrossRefGoogle Scholar
  65. 65.
    Christe C, Janssens JP, Armenian B, Herrmann F, Vogt N. Midazolam sedation for upper gastrointestinal endoscopy in older persons: a randomized, double-blind, placebo-controlled study. J Am Geriatr Soc. 2000;48(11):1398–403.CrossRefGoogle Scholar
  66. 66.
    Katschinski B, Logan R, Davies J, Faulkner G, Pearson J, Langman M. Prognostic factors in upper gastrointestinal bleeding. Dig Dis Sci. 1994;39(4):706–12.CrossRefGoogle Scholar
  67. 67.
    Hammond KL, et al. Implications of negative technetium 99m-labeled red blood cell scintigraphy in patients presenting with lower gastrointestinal bleeding. Am J Surg. 2007;193:404–7.CrossRefGoogle Scholar
  68. 68.
    Green BT, et al. Urgent colonoscopy for the evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol. 2005;100:2395–402.CrossRefGoogle Scholar
  69. 69.
    Laine L, Sahota A, Shah A. Does capsule endoscopy improve outcomes in obscure gastrointestinal bleeding? Randomized trial versus dedicated small bowel radiography. Gastroenterology. 2010;138(5):1673.e1–80.e1; quiz e11–2CrossRefGoogle Scholar
  70. 70.
    Orlando G, Luppino IM, Lerose MA, Gervasi R, Amato B, Silecchia G, Puzziello A. Feasibility of capsule endoscopy in elderly patients with obscure gastrointestinal bleeding. An up-to-date report. BMC Surg. 2012;12(Suppl 1):S30.  https://doi.org/10.1186/1471-2482-12-S1-S30.CrossRefPubMedPubMedCentralGoogle Scholar
  71. 71.
    Baradarian R, et al. Early intensive resuscitation of patients with upper gastrointestinal bleeding decreases mortality. Am J Gastroenterol. 2004;99:619–22.CrossRefGoogle Scholar
  72. 72.
    Hasselgren G, et al. Risk factors for rebleeding and fatal outcome in elderly patients with acute peptic ulcer bleeding. Eur J Gastroenterol Hepatol. 1998;10:667–72.CrossRefGoogle Scholar
  73. 73.
    Qureshi WA, Zuckerman MJ, Adler DG, Davila RE, Egan JV, Gan SI, et al. ASGE guideline: modifications in endoscopic practice for the elderly. Gastrointest Endosc. 2006;63(4):566–9.CrossRefGoogle Scholar
  74. 74.
    Sarin N, Monga N, Adams PC. Time to endoscopy and outcomes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489–93.CrossRefGoogle Scholar
  75. 75.
    Gilbert DA, Silverstein FE, Tedesco FJ. National ASGE survey on upper gastrointestinal bleeding: complications of endoscopy. Dig Dis Sci. 1981;26(7 Suppl):55S–9.CrossRefGoogle Scholar
  76. 76.
    Gilbert DA, Silverstein FE, Tedesco FJ, Buenger NK, Persing J. The national ASGE survey on upper gastrointestinal bleeding. III. Endoscopy in upper gastrointestinal bleeding. Gastrointest Endosc. 1981;27(2):94–102.CrossRefGoogle Scholar
  77. 77.
    Lipof T, Sardella WV, Bartus CM, Johnson KH, Vignati PV, Cohen JL. The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding. Dis Colon Rectum. 2008;51(3):301–5.CrossRefGoogle Scholar
  78. 78.
    Kuo WT. Transcatheter treatment for lower gastrointestinal hemorrhage. Tech Vasc Interv Radiol. 2004;7(3):143–50.CrossRefGoogle Scholar
  79. 79.
    Bandi R, Shetty PC, Sharma RP, Burke TH, Burke MW, Kastan D. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol. 2001;12(12):1399–405.CrossRefGoogle Scholar
  80. 80.
    Kuo WT, Lee DE, Saad WE, Patel N, Sahler LG, Waldman DL. Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol. 2003;14(12):1503–9.CrossRefGoogle Scholar
  81. 81.
    Clark RA, Colley DP, Eggers FM. Acute arterial gastrointestinal hemorrhage: efficacy of transcatheter control. Am J Roentgenol. 1981;136(6):1185–9.CrossRefGoogle Scholar
  82. 82.
    Clarke MG, Bunting D, Smart NJ, Lowes J, Mitchell SJ. The surgical management of acute upper gastrointestinal bleeding: a 12-year experience. Int J Surg. 2010;8(5):377–80.CrossRefGoogle Scholar
  83. 83.
    Gianfrancisco JA, Abcarian H. Pitfalls in the treatment of massive lower gastrointestinal bleeding with “blind” subtotal colectomy. Dis Colon Rectum. 1982;25(5):441–5.CrossRefGoogle Scholar
  84. 84.
    Setya V, Singer JA, Minken SL. Subtotal colectomy as a last resort for unrelenting, unlocalized, lower gastrointestinal hemorrhage: experience with 12 cases. Am Surg. 1992;58(5):295–9.PubMedGoogle Scholar
  85. 85.
    Bender JS, et al. Morbidity and mortality following total abdominal colectomy for massive lower gastrointestinal bleeding. Am Surg. 1991;57:536–40.PubMedGoogle Scholar
  86. 86.
    Sung J, Lau J, Ching J, et al. Early reintroduction of aspirin with proton pump inhibitor after endoscopic hemostasis for peptic ulcer bleeding. Gut. 2007;56:A27.CrossRefGoogle Scholar
  87. 87.
    Pilotto A. Helicobacter pylori-associated peptic ulcer disease in older patients: current management strategies. Drugs Aging. 2001;18:487–94.CrossRefGoogle Scholar
  88. 88.
    Pilotto A, Franceschi M, Di Mario F, et al. The long-term clinical outcome of elderly patients with Helicobacter pylori-associated peptic ulcer disease. Gerontology. 1998;44:153–8.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Paola Fugazzola
    • 1
  • Giulia Montori
    • 1
  • Camilla Bing
    • 2
  • Fausto Catena
    • 3
  • Massimo Sartelli
    • 4
  • Luca Ansaloni
    • 1
  • Federico Coccolini
    • 1
  1. 1.General, Emergency and Trauma Surgery DepartmentPapa Giovanni XXIII HospitalBergamoItaly
  2. 2.General Surgery DepartmentSan Giuseppe HospitalEmpoliItaly
  3. 3.Emergency Surgery DepartmentParma University HospitalParmaItaly
  4. 4.General and Emergency Surgery DepartmentMacerata HospitalMacerataItaly

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