Gastrointestinal Bleeding In Elderly Patients Research Articles

Gastrointestinal bleeding in elderly patients with atrial fibrillation: prespecified All Nippon Atrial Fibrillation in the Elderly (ANAFIE) Registry subgroup analysis

Gastrointestinal (GI) bleeding control is critical in elderly patients with atrial fibrillation (AF) receiving oral anticoagulants (OAC). This subgroup analysis aimed to clarify the actual state and significance of GI bleeding in elderly non-valvular AF (NVAF) patients. We evaluated the incidence and risk factors of GI bleeding during the 2-year follow-up and examined the GI bleeding impact on mortality. Of the 32,275 patients in the ANAFIE Registry, 1139 patients (3.5%) experienced GI bleeding (incidence rate, 1.92 events per 100 person-years; mean follow-up, 1.88 years); 339 upper and 760 lower GI bleeding events occurred. GI bleeding risk factors included age ≥ 85 years, body mass index ≥ 25.0 kg/m2, prior major bleeding, hyperuricaemia, heart failure, P-glycoprotein inhibitor use, GI disease, and polypharmacy (≥ 5 drugs). No significant differences in GI bleeding risk were found between direct OAC (DOAC) vs warfarin users (adjusted hazard ratios [95% confidence interval], 1.01 [0.88–1.15]). The 1-year post-GI bleeding mortality rate was numerically higher in patients with upper (19.6%) than lower GI bleeding (8.9%). In elderly Japanese NVAF patients, this large-scale study found no significant difference in GI bleeding risk between DOAC vs. warfarin users or 1-year mortality after upper or lower GI bleeding.

Novel risk score for acute upper gastrointestinal bleeding in elderly patients: a single-centre retrospective study

ObjectivesAcute upper gastrointestinal bleeding (UGIB) is a common reason for emergency hospital admission. Identifying low-risk patients suitable for outpatient management is a clinical and research priority. This study aimed to...

Gurvits syndrome: a case of acute esophageal necrosis associated with diabetic ketoacidosis

BackgroundAcute esophageal necrosis (AEN), commonly referred to as Gurvits syndrome or “black esophagus”, is a rare clinical disease. We present a case of AEN associated with diabetic ketoacidosis (DKA).Case presentationA 66-year-old male came to our hospital with coffee-ground emesis, dyspnea, and general malaise. He was treated for type 2 diabetes mellitus using insulin and had not been taking his medication, including insulin, for several days. Laboratory analysis revealed severe hyperglycemia (730 mg/dL), normocytic anemia (hemoglobin level, 7.7 g/dL; mean corpuscular volume, 100.4 fL), high serum potassium (7.6 mEq/L), and a high level of blood urea (98.7 mg/dL). Ketones and glucose were detected in the urine, and serum β-hydroxybutyrate was elevated (2132 µmol/L). Arterial blood gas analysis confirmed metabolic acidosis (pH, 7.29; HCO3, 10.5 mmol/L). Collectively, the patient was diagnosed with DKA and upper gastrointestinal bleeding. The patient’s condition improved with intravenous fluids, and he received intravenous insulin to treat DKA. According to these findings, the patient was diagnosed with DKA and upper gastrointestinal bleeding. The patient underwent esophagogastroduodenoscopy (EGD) which revealed a circumferential necrosis of the middle and distal esophagus, immediately proximal to the gastroesophageal junction. The patient was then treated with an intravenous proton pump inhibitor. The patient continued to improve with conservative treatment and was subsequently discharged in a stable condition. An EGD repeated 14 days after discharge showed complete healing of the necrotic-like mucosal change without stricture formation of the esophagus.ConclusionsAEN is rare but potentially life-threatening case of upper gastrointestinal bleeding. Therefore, a clinician should be aware of AEN as a potential cause of upper gastrointestinal bleeding in elderly patients with poorly controlled diabetes and significant comorbidities.

Daily Usage of Proton Pump Inhibitors May Reduce the Severity of Critical Upper Gastrointestinal Bleeding in Elderly Patients

Introduction We retrospectively examined the relationship between daily proton pump inhibitor (PPI) use and severity of upper gastrointestinal bleeding (UGIB), mainly in the elderly. Methods We included 97 patients with nonvariceal UGIB diagnosed at our hospital from January 2012 to October 2017. Bleeding severity was assessed using the shock index (SI) and estimated bleeding volume; 49 patients met the criterion for the mild group and 48 for the moderate/severe group. The effect of PPI use on bleeding severity was compared between the groups. The relationships of PPI use and dose with the clinical symptoms of UGIB were also analyzed. Results Among the 97 patients, 17 (17.5%) habitually used PPIs. The rate of habitual PPI use was significantly higher in the mild group, indicating as an independent factor contributing to a reduction in the severity of UGIB in a multiple logistic regression analysis (30.6% vs. 4.2%; OR 10.147; 95% CI 2.174–47.358, P < 0.01). When analyzing data for a subgroup of patients older than 75 years, we found the protective PPI effect to be even higher in the mild UGIB group than in the moderate/severe group (37.0% vs. 5.6%; OR 10.000; 95% CI 1.150–86.951, P < 0.05). Conversely, we found no association between PPI prescription and UGIB symptoms in patients younger than 75 years. The mean estimated bleeding volume and SI in the 17 habitual PPI users were both significantly less than those among the 80 nonhabitual users, respectively (P < 0.05). The proportion of patients with mild UGIB was similar between the low- and high-dose PPI users. Conclusions Particularly in elderly patients with nonvariceal UGIB, habitual PPI use can alleviate the clinical symptoms of UGIB by suppressing the volume of bleeding, regardless of the adapted dose of PPIs.

Bleeding Complications in Atrial Fibrillation Patients on Anticoagulant Therapy

The risk of bleeding in atrial fibrillation patients on direct oral anticoagulant treatment increases with age; particularly dabigatran is associated with a higher risk of gastrointestinal bleeding in elderly patients, low body mass ([48 kg) and women due to the induced dyspepsia. We aimed to evaluate the safety of direct oral anticoagulants (DOAC) dabigatran, rivaroxaban and apixaban by comparing each agent with a widely used vitamin K antagonist (VKA)-acenocoumarol in terms of bleeding event rates. A retrospective study regarding bleeding events in atrial fibrillation patients treated with oral anticoagulation (OAC) was performed. Haematuria, epistaxis and haemoptysis were considered minor events and intracranial bleeding, gastrointestinal bleeding (superior or inferior), blood transfusion after haemorrhagic events linked to OAC treatment were considered to be major events. A number of 219 atrial fibrillation patients were included using electronic medical records: 118 patients treated with DOAC s (82 using dabigatran, 28 on rivaroxaban regimen and 8 cases treated with apixaban) and 101 cases had vitamin K antagonists treatment (acenocumarol). A total of 75 bleeding events were encountered (70 minor and 5 major). A higher number of events were encountered in patients treated with DOAC s, but with no statistically significant difference compared to acenocumarol. The associated risk factors did not play a decisive role in bleeding events in the two treatment groups. No statistical significant difference was noted between the occurrence of haemorrhagic events and the class of oral anticoagulant treatment used (DOAC vs. VKA).

Clinical and endoscopic features of severe acute gastrointestinal bleeding in elderly patients treated with direct oral anticoagulants: a multicentre study.

Background:The aim of the study was to describe the clinical and endoscopic characteristics and management of severe acute gastrointestinal (GI) bleeding in patients treated with direct oral anticoagulants (DOACs).Methods:Patients hospitalized for severe GI bleeding under DOAC therapy were identified in 36 centres between June 2013 and March 2016. Clinical outcomes including re-bleeding, major cerebral and cardiovascular events or all-cause mortality were assessed initially and 30 days after admission.Results:A total of 59 patients with anonymized detailed endoscopy reports for severe GI bleeding were considered. Mean age was 79.3 ± 10.0 years and 61.3% of patients were men. Patients had histories of hypertension (65.6%), heart failure (29.5%), coronary artery disease (27.9%), stroke (19.7%) and peripheral vascular disease (36.1%). Life-threatening bleeding was observed in 42.6%. Mean number of packed red blood cells transfused was 3.4 (range 1–31). Aetiology of bleeding (identified in 66.2% of cases) was peptic gastroduodenal ulcers (22%), diverticula (11.9%), angiodysplasia (8.5%), colorectal neoplasia (5.1%) and anorectal causes (5.1%). Endoscopic haemostasis was performed in 37.7% of patients. A low haemoglobin level was predictive of life-threatening bleeding and death in multivariate analysis. All-cause mortality rate at day 30 was 11.8%.Conclusions:In this cohort of elderly patients with multiple comorbidities treated with DOACs, the main cause of severe acute GI bleeding was peptic gastroduodenal ulcer and mortality was high.

Mortality rate and risk factors for gastrointestinal bleeding in elderly patients

BackgroundGastrointestinal bleeding (GIB) is burdened by high mortality rate that increases with aging. Elderly patients may be exposed to multiple risk factors for GIB. We aimed at defining the impact of GIB in elderly patients. MethodsSince 2008, samples of elderly patients (age ≥ 65 years) with multimorbidity admitted to 101 internal medicine wards across Italy have been prospectively enrolled and followed-up (REPOSI registry). Diagnoses of GIB, length of stay (LOS), mortality rate, and possible risk factors, including drugs, index of comorbidity (Cumulative Illness Rating Scale [CIRS]), polypharmacy, and chronic diseases were assessed. Adjusted multivariate logistic regression models were computed. Results3872 patients were included (mean age 79 ± 7.5 years, F:M ratio 1.1:1). GIB was reported in 120 patients (mean age 79.6 ± 7.3 years, F:M 0.9:1), with a crude prevalence of 3.1%. Upper GIB occurred in 72 patients (mean age 79.3 ± 7.6 years, F:M 0.8:1), lower GIB in 51 patients (mean age 79.4 ± 7.1 years, F:M 0.9:1), and both upper/lower GIB in 3 patients. Hemorrhagic gastritis/duodenitis and colonic diverticular disease were the most common causes. The LOS of patients with GIB was 11.7 ± 8.1 days, with a 3.3% in-hospital and a 9.4% 3-month mortality rates. Liver cirrhosis (OR 5.64; CI 2.51–12.65), non-ASA antiplatelet agents (OR 2.70; CI 1.23–5.90), and CIRS index of comorbidity >3 (OR 2.41; CI 1.16–4.98) were associated with GIB (p < 0.05). ConclusionsA high index of comorbidity is associated with high odds of GIB in elderly patients. The use of non-ASA antiplatelet agents should be discussed in patients with multimorbidity.

Clinical value of interventional treatment in pancreatogenic portal hypertension complicated by gastrointestinal bleeding in elderly patients

Clinical value of interventional treatment in pancreatogenic portal hypertension complicated by gastrointestinal bleeding in elderly patients

Development of Bleeding Gastric Arteriovenous Malformations in a 23-year-old Man 3 Months After Normal Endoscopy

Gastric arteriovenous malformations (AVMs) are extremely rare. AVMs can develop in the stomach, large and small intestine. They are typically seen in elderly patients and are most commonly found in the large intestine. They are a significant cause of lower gastrointestinal bleeding in elderly patients. AVMs are more common in patients with end-stage kidney disease, Von Willebrand disease and have been found to be associated with aortic stenosis. A 23 year-old Caucasian male was brought in to the hospital by his mother after he had an episode of coffee ground emesis associated with fever and a low oxygen saturation level measured at home by his caretaker. He has a past medical history of an anoxic brain injury from a childhood drowning accident at age 4, with a gastrojejunostomy tube for feeding. In the emergency room, he was found to have hypoxia and was admitted to the hospital. His physical exam revealed blood pressure of 73/51 and an oxygen saturation of 85%. Admission labs revealed hemoglobin of 15.3 g/dl, hematocrit of 43.8%, MCV 94.2 and WBC 8,900. A chest x-ray performed during hospitalization revealed a left lung consolidation suspicious for possible aspiration pneumonia. Blood work on the following day showed his hemoglobin had dropped to 7.9 g/dl with a hematocrit of 23% and he continued to have episodes of coffee ground emesis. An endoscopy was performed that revealed several medium-sized angiodysplastic lesions with stigmata of recent bleeding in the gastric body and underneath the g-tube bumper. Hemostasis was achieved with argon laser and the patient did not have any further episodes of hematemesis. The patient had a previous endoscopy that was performed 3 months prior to hospitalization evaluating for reflux esophagitis which had revealed normal gastric and duodenal mucosa. No AVMs were seen at that time. In this case, a young male patient developed gastric AVMs in a span of 3 months that were associated with significant bleeding, leading to aspiration pneumonia. The patient does not have end-stage renal disease, aortic stenosis or Von Willebrand disease. The pathogenesis of AVMs of the gastrointestinal tract is not well understood. In this patient, it is possible that previous hospitalization with significant hypoxia may have led to the increased expression of angiogenic factors which may be the underlying reason for the development of arteriovenous malformations of the stomach in a short period of time.Figure: Endoscopic view of multiple a/v malformations in patient's stomach.Figure: Endoscopy performed 3 months ago.

Management for non-variceal upper gastrointestinal bleeding in elderly patients: the experience of a tertiary university hospital.

Peptic ulcer bleeding (PUB) is the main cause of non-variceal upper gastrointestinal bleeding (UGIB). Endoscopic treatment and acid suppression with proton-pump inhibitors (PPIs) are most important in the management of PUB and these treatments have reduced mortality. However, elderly patients sometimes have a poor prognostic outcome due to severe comorbidities. A retrospective study was performed on 504 cases with acute non-variceal UGIB who were examined in our hospital, in order to reveal the risk factor of a poor outcome in elderly patients. Two hundred and thirty-four cases needed hemostasis; 11 cases had unsuccessful endoscopic treatments; 31 cases had re-bleeding after endoscopic hemostasis. Forty-three cases died within 30 days after the initial urgent endoscopy, but only seven cases died from bleeding. Elderly patients aged over 65 years had more severe comorbidities, and were prescribed non-steroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents and/or anticoagulation agents, more frequently, compared with non-elderly patients. The significant risk factor of needing hemostatic therapy was the taking of two or more NSAIDs, antiplatelet agents and/or anticoagulation agents. The most important risk of a poor outcome in elderly patients was various kinds of severe comorbidities. And so, it is important to predict such an outcome in these cases. AIMS65 is a simple and relatively useful scoring system that predicts the risk of a poor outcome in UGIB. High-score patients via AIMS65 were associated with a high mortality rate because of death from comorbidities. The elderly patients in whom were prescribed two or more NSAIDs, antiplatelet agents and/or anticoagulation agents, should have UGIB prevented using a PPI. The most significant risk of a poor outcome in elderly patients was severe comorbidities. We recommend that elderly patients with UGIB should be estimated as having a poor outcome as soon as possible via the risk scoring system AIMS65.

Frequency of Upper Gastrointestinal Bleeding in Elderly Patients with Iron Deficiency Anaemia Presented at Liaquat University Hospital Jamshoro

Objective: To determine the frequency of upper gastrointestinal bleeding in elderly patients with iron deficiency anemia present at Liaquat University Hospital Jamshoro. Subject and methods: Total 100 subjects of conformed upper gastrointestinal bleeding aged 60 years and above, with iron deficiency anemia were enrolled in the study. All other patients who were not meet to inclusive criteria were excluded from study, all patients were subjected to thorough checking of blood CP, ferritin. All patients were than undergone, upper GI endoscopy in which presence/absence of bleeding site determined, data were analyzed on SPSS version 16. Results: A total of 100 subjects with iron deficiency anemia were examined in this study. Overall 91% had upper gastrointestinal findings at endoscopy. Out of 100 subjects, 62 (62%) were males and 38 (38%) were females. Out of these 42 (42%) had got bleeding source in the stomach, 36 (36%) patients had bleeding source in the duodenum, 13 patients had got bleeding source in the esophagus the remaining 9 patients had got no source of bleeding after thorough upper GI endoscopy. Out of 62 males, 26 (41.93%) had bleeding source in the stomach, 22 males (35.48%) had Bleeding source in the duodenum, 8 (12.90%) had bleeding source in the esophagus and 6 (9.67%) males had no lesion identified. While in total 38 females, 16 (42.1%) had bleeding source in the stomach, 14 (36.84%) had bleeding source in the duodenoum, 5 (13.15%) had Bleeding source in the esophagus and 3 (7.89%) had no bleeding source identified. The mean age of the patients recruited in this study was 66.9 with standard deviation of 6.47 with minimum 60 and maximum 80 years. Males are affected more than females. Maximum number of the patients with UGIB fall in 60-65 years age groups. Males and females between 60-65 years were found to have UGIB in stomach. Conclusion: In this study, it was conducted that frequency of blood loss in elderly is from stomach followed by duodenum and esophagus. Upper GI endoscopy is investigation of choice in evaluation of patients suspected as bleeding from Upper gastro intestinal tract.

Endoscopic hemostat combined with different doses of proton pump inhibitor for management of acute non-varicose upper gastrointestinal bleeding in elderly patients

Endoscopic hemostat combined with different doses of proton pump inhibitor for management of acute non-varicose upper gastrointestinal bleeding in elderly patients

Pantoprazole for prevention and treatment of gastrointestinal bleeding in elderly patients after percutaneous coronary intervention

Pantoprazole for prevention and treatment of gastrointestinal bleeding in elderly patients after percutaneous coronary intervention

Venlafaxine and Risk of Upper Gastrointestinal Bleeding in Elderly Depression

In the past 10 years there has been an emphasis on the risk of upper gastrointestinal bleeding in patients taking SSRI antidepressants. Few studies have concurrently examined the possible risk of traditional antidepressants or atypical antidepressants such as venlafaxine, classified as a serotonin-norepinephrine reuptake inhibitor. In order to promote debate about possible risk of upper gastrointestinal bleeding in elderly patients taking antidepressants different from SSRIs, we report a case of venlafaxine-induced upper gastrointestinal bleeding in a 84 years old woman. Discussion about safer drugs and protective factors is provided.

Presentation, distribution pattern, and management of diverticular disease in a Nigerian tertiary hospital

Colonic diverticular disease is one of the most common and costly gastrointestinal disorders among industrialized societies, which have recently been described among Africans. Presentations and distribution pattern of the disease among Africans appeared to be different from that described among the Western population. We embark on this study aimed at evaluating the presentation, distribution pattern, and the management of diverticulosis in our tertiary health facility. A prospective descriptive study of the cases of diverticular disease seen between January 2007 and December 2011 at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria. During the 5-year study period, 40 cases were seen. The patients were aged 41-85 years with a median age of 64 years. There were 29 (72.5%) male and 11 (27.5%) female with an average male to female ratio of 3:1. The most common presentation was bleeding per rectum in 28 (70%) patients, which mostly needed transfusion. Ten (25%) patients presented with recurring abdominal pain, whereas one (2.5%) patient presented with abdominal mass and features of intestinal obstruction. Thirty patients were diagnosed on colonoscopy, eight on barium enema, and two on computerized tomography scan. Thirty-four (85%) patients had a pancolonic disease. All the patients were placed on high fiber diet and antibiotics namely ciprofloxacin and metronidazole. Five patients had recurrence within 6 months of follow up, of which one had emergency colectomy. Diverticular disease is no longer a rare disease in Nigeria. It is a common cause of lower gastrointestinal bleeding in elderly patients. High index of suspicion for diverticular disease of the colon and its complications should increase in the country.

Venlafaxine and Risk of Upper Gastrointestinal Bleeding in Elderly Depression

In the past 10 years there has been an emphasis on the risk of upper gastrointestinal bleeding in patients taking SSRI antidepressants. Few studies have concurrently examined the possible risk of traditional antidepressants or atypical antidepressants such as venlafaxine, classified as a serotonin-norepinephrine reuptake inhibitor. In order to promote debate about possible risk of upper gastrointestinal bleeding in elderly patients taking antidepressants different from SSRIs, we report a case of venlafaxine-induced upper gastrointestinal bleeding in a 84 years old woman. Discussion about safer drugs and protective factors is provided.

Gastrointestinal bleeding associated with antithrombotic therapy in the elderly in Japan.

We summarize data of patients with gastrointestinal bleeding (GIB) and discuss the relationship between antithrombotic drug use and age in patients with GIB. One-hundred and twenty patients with GIB were divided into two groups according to age (=75 years old and <75 years old). The causes and clinical outcome of each group were compared. Forty-two patients received antithrombotic therapy. The main antithrombotic drugs were low dose aspirin (38 patients), ticlopidine (5 patients) and warfarin (3 patients). Compared with younger GIB patients, elderly patients had more coexisting illness and antithrombotic drugs. In patients taking antithrombotic drugs, upper GIB is more frequent than those not taking antithrombotic drugs (p<0.05) and antithrombotic drugs were the risk for GIB from erosive lesions of the esophagus or stomach. In the lower gastrointestinal tract, there was no difference of incidence related to antithrombotic use. The initial endoscopic hemostasis was performed in 14 patients. Eight varices patients received endoscopic vanding and 6 of 43 gastroduodenal ulcer patients had mechanical clip hemostasis. From our findings, antithrombotic drugs were considered to be a risk for GIB. It might be important to prevent or minimize GIB in elderly patients prescribed antithrombotic drugs.

Upper gastrointestinal bleeding in elderly patients in a Tunisian hospital: A retrospective study

Background and study aims The older age group presents a major problem in the management of acute gastrointestinal bleeding with a relatively high mortality. The study aims to describe the background characteristics, causes and outcome of acute upper gastrointestinal bleeding in the elderly in Tunisia. Patients and methods We retrospectively reviewed data of 401 patients aged ⩾ 60 years presenting with upper gastrointestinal bleeding. Information collected included history, physical examination findings, laboratory data, endoscopic findings and length of hospital stay. Patients were divided into two groups: group A (65–79 years) and group B (>79 years). Results Group A included 315 patients and group B 86 patients. There was a male preponderance in both groups. Co-morbidity ( p < 0.01) and use of non-steroidal anti-inflammatory drugs (NSAIDs) or anti-platelet drugs ( p < 0.01) were more common in group B. Oesophagitis was the cause of bleeding in 38.37% in group B, as compared with 19% in group A. The main cause of bleeding in group A was peptic ulcer. Rebleeding (6/86) and emergency surgery (1/86) were rare in group B and not different from those in group A. However, the bleeding-related mortality in the very elderly group was higher (13.9% vs. 4.76%; p = 0.02). In multivariate analysis, only shock on admission was independently related to mortality ( p = 0.02). Conclusion Oesophagitis is the major cause of upper gastrointestinal haemorrhage in the very elderly patients. While rebleeding and emergency surgery rates are relatively low, the bleeding-related mortality was higher in the very elderly group.

Polypoid angiodysplasia: an unusual cause of lower gastrointestinal bleeding

Angiodysplasia is one of the most leading causes of lower gastrointestinal bleeding in elderly patients. Polypoid angiodysplasia is extremely rare; however, in the literature, a few cases have been reported as single polypoid lesion from Eastern countries. The lesions in our case were multiple polypoid, octopus-like, and were associated with diverticula. We managed to remove the polypoid angiodysplasia using snare polypectomy. This is the first reported case of multiple polypoid angiodysplasia associated with diverticula.

Intestinal angiodysplasia and aortic valve stenosis: let's not close the book on this association

The association between gastrointestinal (GI) bleeding due to angiodysplasia of the large intestine and calcific aortic stenosis (AS) has been a matter of debate. Recent studies suggest that this association is related to subtle alterations in plasma coagulation factors. von Willebrand factor is the strongest possible link between aortic stenosis and bleeding associated with GI angiodysplasia. Physicians should be aware of this entity when dealing with elderly patients presenting either with GI bleeding or with AS. A high index of suspicion and appropriate diagnostic procedures followed by prompt treatment could be life saving. Several questions related to the pathogenesis and optimal management remain unanswered. Aortic valve replacement appears to offer the best hope of long-term resolution of the bleeding, and should be considered in most cases. The association between chronic gastrointestinal bleeding in elderly patients and aortic stenosis becomes more relevant with the advent of transcatheter aortic valve implantation which can be offered even to elderly patients with comorbidities which could make conventional surgery impossible.