Upper GI Bleeding Caused by Severe Esophagitis or Esophageal Ulcers?

Abstract

We read with great interest the recently published article by Guntipalli et al. [1]. They aimed to show the rates of gastrointestinal bleeding in erosive esophagitis. They indicate that this study described a unique clinical syndrome in patients with upper gastrointestinal bleeding who have erosive esophagitis. We thank Guntipalli et al. for this study, but think there are some controversial situations that need to be clarified. They mention that they designed the groups as those having esophagitis or having other primary bleeding lesions, including gastric ulcer, duodenal ulcer, portal hypertensive gastropathy, Mallory-Weiss tear, esophageal varices, gastric cancer, or a primary source of bleeding not from the esophagus based on retrospective data analysis. They indicated in this article that they found esophagitis as a cause of nearly 25 % of severe bleeding in their hospital. But in our current practice, we do not observe esophagitis as a cause of severe upper gastrointestinal bleeding at that rate. Consistently, in a recent study, Kim et al. [2] found esophageal ulcers at 2.1 % and esophagitis at 8.1 % as a cause of all of upper gastrointestinal system bleeding. Second, it is known that mucosal lesions such as erosions are confined to the mucosa, and severe hemorrhage occurrence is unlikely. In contrast, ulcers extend into the submucosa, and deeper and severe bleeding results when ulcers erode into the vessels below the mucosa [3]. However, in this study, the rate of esophageal ulcers in the esophagitis group was not mentioned. The authors also indicated that erosive esophagitis was determined based on the Los Angeles (LA) Classification. However, the LA classification, which is a popular modern system for grading the severity of reflux esophagitis, avoids the problem of distinguishing erosions from ulcerations by referring to both as mucosal breaks [4]. Thus, it is difficult to distinguish between ulcer and erosion with this classification. In contrast, the Savary-Miller classification includes ulcers and other complications [5]. Although it has limitations, it would be better to identify the reason for gastrointestinal bleeding, whether it is from erosion or its complications. Thus, as a result, we think that the rate of esophageal peptic ulcers might be distinguished from erosion to determine the exact rate of esophagitis in severe gastrointestinal bleeding.