Objective: To find out the diagnosis in patients presented with acute upper gastrointestinal hemorrhage at King Hussein Medical Centerl.
Methods: A total of 1118 cases of acute upper gastrointestinal hemorrhage patients aged over 16 years who underwent upper endoscopy over 6 year-period at King Hussein Medical Center. Most endoscpies were done within 24 hours from the occurrence of the gastrointestinal bleeding. Patients were divided into different age groups to compare the frequency of upper gastrointestinal hemorrhage between males and females in each group. Again, the total number of patients were divided into 2 subgroups; those < 50 years, and > 50 to compare the distribution of the endoscopic findings between young and older age groups.
Results: Upper gastrointestinal bleeding was more common in men at all age groups than that in women, except in elderly patients (more than 70 years). Eighty seven percent of the endoscopies were done for patients admitted to Hospital through the emergency department, and 13% for patients who were already in hospital for some other reason. Sixty two percent of patients aged over 50. The most common finding over all was duodenal ulcer (32%). Normal endoscopy was reported in 21%. Other frequent sources of bleeding were stomach ulcers (18.5%), esophageal varices (5.2%), portal hypertensive gastropathy in (0.6%), Mallory-Weiss tear in (3.3%), and gastric tumor in (4.7%). Gastric ulcer and malignancy were more common in older compared with young age group (21.5%, 6.6% vs. 14%, 1.4% respectively). Therapeutic endoscopic interventions were done for (17%) patients: Adrenaline injection for bleeding peptic ulcer (16%), sclerotherapy for esophageal varices in (0.9%) patients, and banding in (0.1%).
Conclusions: The frequency of acute upper gastrointestinal hemorrhage increases considerably with age. The most common finding for all age groups was duodenal ulcer. Malignancy was the most important finding in the older (> 50 years) age group.
Key word: Bleeding, Gastrointestinal hemorrhage, Peptic ulcer.
JRMS April 2009; 16(1):5-9
IntroductionAcute upper gastrointestinal hemorrhage remains a common reason for admission into hospital.(1,2) Early endoscopic intervention has been shown to improve outcome in the management of patients with upper gastrointestinal (GI) hemorrhage.(3,4)
The most common causes of upper gastrointestinal bleeding are chronic duodenal ulcers, chronic gastric ulcers, esophageal varices, gastric varices, Mallory-Weiss tears, acute hemorrhagic gastritis, and gastric neoplasms. Less common causes include various other gastrointestinal conditions and certain hepatobiliary and pancreatic disorders.(5)
Upper gastrointestinal hemorrhage may present as severe bleeding with hematemesis, hematochezia, and hypotension; as gradual bleeding with melena; or as occult bleeding, detected by positive tests for blood in the stool.(6) The initial steps in the evaluation of patients with upper GI bleeding are based on the perceived rate of bleeding and the degree of hemodynamic stability. Hemodynamically stable patients who show no evidence of active bleeding or co morbidities and in whom endoscopic findings are favorable may be treated on an outpatient basis, whereas patients who show evidence of serious bleeding should be managed aggressively and hospitalized.(7)
Esophagogastroduodenoscopy (EGD) usually reveals the source of upper GI bleeding. It requires considerable skill: identification of bleeding sites in a blood-filled stomach is far from easy.(8,9) In case of hematemesis, emergency EGD is indicated, usually within 6 hours of presentation. If the rate of bleeding is high, saline lavage may be performed to clear the stomach of blood and clots.(4)
EGD is not only an excellent diagnostic tool but also a valuable therapeutic modality. The choice of therapy depends on the cause, the site, and the rate of bleeding.(10-13)
We report the results of a retrospective study of the outcome of an 1118 patients presented with upper gastrointestinal bleeding and undergone upper endoscopy with or without therapeutic endoscopic interventions.
MethodsOur data were collected from the records of the gastrointestinal unit over 6 years for all patients presented with acute upper gastrointestinal hemorrhage. The study was conducted at King Hussein Medical Center (KHMC) which is a military hospital related to the Royal medical services in Amman. KHMC is a tertiary hospital; receive referrals from all medical sectors in Jordan. It serves the armed forces and the dependents.
All major specialties and subspecialties are represented. Acute upper gastrointestinal hemorrhage was defined as a hematemesis or the passage of melena or other firm clinical or laboratory evidence of blood loss from the upper gastrointestinal tract. Hematemesis was defined as vomiting of blood or blood clots. Melena was defined as passage of dark, tarry stools witnessed by nursing or medical staff or discovered on rectal examination.
Data collected included; age, sex, endoscopic findings, and histopathological results when a biopsies were taken. Patients were included in the study if they were aged 16 years or older and had clinical evidence of acute upper gastrointestinal bleeding on admission through emergency department, or clinical evidence of acute upper gastrointestinal bleeding while an established inpatient for any other reason. Most endoscopies were done within 24 hours of admission to Hospital or referral from the wards. Gastric biopsies for Helicobacter pylori in case of peptic ulcer were not routinely taken as well as rapid urease test is not available in King Hussein Medical Center.
Patients were divided into different age groups to compare the frequency of upper gastrointestinal hemorrhage between males and females. Again, the total numbers of patients were divided into 2 subgroups; those < 50 years, and > 50 to compare the distribution of the endoscopic findings between young and older age groups.
ResultsA total of 1118 adults undergone upper endoscopy at the gastroenterology unit in King Hussein Medical Center over 6 years, with a mean age of 54 years (range 16 to 100). Six hundred eighty two (61%) patients were males. Nine hundred seventy three (87%) of cases were emergency admissions, and 13% were hemorrhages in inpatients who already were in hospital for some other reason. The frequency of upper gastrointestinal bleeding was more in men in all age groups compared with women except in those aged 70 or over as shown in Table I.
When comparing inpatients and those admitted through emergency department, the distribution of diagnoses was similar except that Mallory-Weiss lesions were more common in those admitted urgently.
Table I: Number of cases of acute upper gastrointestinal hemorrhage by gender
|
Age
(years)
|
Male n=682
|
Female n=436
|
Total
n=1118
|
|
16-29
|
120
|
34
|
154 (14%)
|
|
30-39
|
101
|
36
|
137 (12%)
|
|
40-49
|
97
|
48
|
145 (13%)
|
|
50-59
|
77
|
36
|
113 (10%)
|
|
60-69
|
138
|
95
|
233 (22%)
|
|
70
and more
|
149
|
198
|
347 (31%)
|
Underlying cause for the upper Gastrointestinal bleeding were found in 883 (79%) patients and no source of bleeding was found in 235 (21%) patients as shown in Table II.
Table II: Main endoscopic finding explaning the cause of bleeding by age
|
Diagnosis
|
Age <50 (%)
n= 425
|
Age >50 (%)
n=693
|
All patients (%)
n= 1118
|
|
Duodenal
ulcer
|
141 (33)
|
217(31)
|
358(32)
|
|
No
lesion found
|
114 (27)
|
121(17.5)
|
235(21)
|
|
Gastric
ulcer
|
58 (14)
|
149(21.5)
|
207(18.5)
|
|
Gastric
erosion
|
31(7.3)
|
38(5.5)
|
69(6.2)
|
|
Esophagitis
|
19 (4.5)
|
43(6.2)
|
62(5.5)
|
|
Esophageal
varices
|
17 (4)
|
41(5.9)
|
58(5.2)
|
|
Tumours
|
6 (1.4)
|
46(6.6)
|
52(4.7)
|
|
Mallory-Weiss tear
|
24 (5.6)
|
13(1.9)
|
37(3.3)
|
|
Doudenitis
|
12 (2.8)
|
17(2.5)
|
29(2.6)
|
|
Portal
hypertensive gastropathy
|
2 (0.47)
|
5(0.7)
|
7(0.6)
|
|
Angiodysplasia
|
1 (0.2)
|
3(0.4)
|
4(0.4)
|
|
More
than one finding
|
27(6.2)
|
62(8.9)
|
89 (8)
|
The most common finding over all was duodenal ulcer. Eight percent of the patients had more than one abnormal endoscopic finding. Gastric ulcer and malignancy were more common in older age group. Mallory-Weiss tear was more common in the younger age group patients (5.6%) compared with older age group (1.9%).
Therapeutic endoscopic interventions were done for 190 (17%) patients, as shown in Table III.
We compared our results with different international studies done elsewhere.
Table III: Therapeutic endoscopic interventions for the study population
|
Therapeutic intervention
|
Patients (%)
|
|
Total
therapeutic interventions
|
190 (17)
|
|
Adrenaline
injection
|
179 (16)
|
|
Sclerotherapy
for esophageal varices
|
10 (0.9)
|
|
Banding
for esophageal varices
|
2 (0.1)
|
DiscussionAll patients who developed acute gastrointestinal bleeding (Hematemesis tend to have more severe bleeding than those who present with melena alone) usually admitted as an emergency to hospital. Only a small minority of young, fit patients who have self-limiting bleeding can be managed as outpatients, but even those need urgent investigation.(9,14)
Only 62% of our patients were aged over 50, which is different from that in western countries, we found increasing age of the population presenting with acute upper gastrointestinal bleeding same as in other studies,(4,5,6,8) which may be explained by; First: may be a reflection of the increasing age of the whole population in Jordan (347 (31%) of all patients were aged over 70). Second: may be due to the increasing prevalence oh Helicobacter Pylori with age. Third; due to the increasing use of Aspirin, or non-steroidal anti-inflammatory drugs in elderly patients, which could not be defined in numbers in our retrospective study?
Upper gastrointestinal bleeding was more common in men at all age groups than that in women except in elderly patients (more than 70 years). This may be explained by excessive use of NSAID by old women or the life expectancy for women is more than that for men in Jordan.
We compared our results with different international studies done elsewhere.(15-21) Table IV showed a literature survey of causes of upper Gastrointestinal bleeding in different parts of the world. In our study, where underlying cause was found, duodenal ulcer was the most common (32%), and more common than gastric ulcer, which is consistent with other studies.
Variceal hemorrhage is still uncommon in Jordan, being the cause of 5.2% of hemorrhages in this study, while in other studies,(15-20) it is ranging between 9-15.4%, which may explained by low prevalence of hepatitis C, and other diseases which my cause portal hypertension, as Schistosomiasis(21) in Jordan. The prevalence of hepatitis C antibody in healthy blood donors in Jordan is 1.7%.(22)
Table VI: Literature survey of common causes of upper Gastrointestinal bleeding
|
Diagnosis
|
Phillip et al 1980(15)
|
Silverstein et al 1981(16)
|
Kohler et al
1989 (17)
|
Stollman NH
1997(18)
|
Wilcox CM
1999 (19)
|
Golanova J
2004(20)
|
Thomopoulos
KC et al
2004(21)
|
Our study
|
|
Duodenal
ulcer
|
52.4
|
22.8
|
9
|
8
|
28
|
20
|
48.7
|
32%
|
|
Gastric
ulcer
|
28.3
|
21.9
|
24
|
20
|
32
|
18.2
|
19.2
|
18.5%
|
|
Gastric
erosion
|
|
29.6
|
11
|
|
8.2
|
|
|
6.2
|
|
Mallory-Weiss tear
|
1
|
8
|
5
|
8
|
6
|
|
|
3.3
|
|
Duodenitis
|
|
9.1
|
4
|
5.3
|
7
|
|
18.4
|
2.6
|
|
Esophageal
varices
|
11.2
|
15.4
|
14
|
47
|
9
|
10.3
|
13.2
|
5.2
|
|
Esophagitis
|
|
12.8
|
5
|
6.8
|
7.5
|
|
|
5.5
|
|
Tumors
|
9.8
|
3.7
|
4
|
6.1
|
5.7
|
|
|
4.7
|
Hepatitis C virus prevalence rates are estimated to range from 5.5% in Africa, 4.6% in the Eastern Mediterranean region, and 4% in the Western Pacific region.(23)
No source of bleeding found in 21% of patients, which is a high percent. This can be explained by; 1. Lesion missed on endoscopy that most endoscopies done in more than 6 hours of admission, 2. Mucosal lesion healed before patient endoscoped as erosions, Mallory-Weiss tear, or Dieulafoy's lesion, 3. Bleeding from the third part of the duodenum or beyond (Jejunum, Meckel's diverticulum, or colon).(5-7)
Deficiencies in study are; First: the number of patients taking NSAID and steroid was not reported in records, and the state of Helicobacter Pylori was not known as we were not routinely testing for Helicobacter Pylori in cases of acute upper gastrointestinal bleeding. Second: the rate of re-bleeding after therapeutic interventions, repeated endoscopies, and percentage of patients who underwent surgery were not reported. Third: we did not use a special statistical method for analysis of the results.
Conclusions
The frequency of acute upper gastrointestinal hemorrhage increases considerably with age. Upper gastrointestinal bleeding was more common in men at all age groups than that in women except in elderly patients (more than 70 years). The most common finding for all age groups is duodenal ulcer. Malignancy is the most important finding in the older (> 50 years) age group. In young age group, duodenal ulcer, no lesion found, or Mallory-Weiss tear were the most common findings.
References 1.Wei KL, Tung SY, Sheen CH, et al. Effect of oral esomeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. Journal of Gastroenterology and Hepatology 2006; 10: 1440-1746.
2.Zhou Y, Qiao L, Wu J, et al. Comparison of the efficacy of octreotide, vasopressin, and omeprazole in the control of acute bleeding in patients with portal hypertensive gastropathy: A controlled study. Journal of Gastroenterology and Hepatology 2002; 17: 973-975.
3.Yamaguchi Y, Yamato T, Katsumi N, et al. Endoscopic hemostasis: Safe treatment for peptic ulcer patients aged 80 years or older? Journal of Gastroenterology and Hepatology 2003; 18: 521- 525.
4.Gibson R, Hitchcock K, Duggan A. Characteristics of Australian after-hours emergency endoscopy services. J Gastroenterol Hepatol 2006; 21(3): 569-571.
5.Dallal H, Palmer K. ABC of the upper gastrointestinal tract; Upper gastrointestinal hemorrhage. BMJ 2001; 323: 1115-1117.
6.Harold K, Schlinkert R. Upper Gastrointestinal Bleeding: Assessment and Management of Upper Gastrointestinal Bleeding. ACS Surgery Online 2002; ©2002 WebMD Inc.
7.Yw Lau J, Chung S. Management of upper gastrointestinal haemorrhage. Journal of Gastroenterology and Hepatology 2000; 15: G8-G12.
8.Kamha A, Al Kaabi S, Sattar HA. Upper Gastrointestinal Bleeding in the Medical Intensive Care Unit, Doha,Qatar: A one-year survey. Qatar Medical Journal. 2003; 12: 23-25.
9.Saltzman JR, Zawacki JK. Therapy for Bleeding Peptic Ulcers. N Engl J Med 1997; 336: 1091-1093.
10.Lay CS, Tsai YT, Lee FY, et al. Endoscopic variceal ligation versus propranolol in prophylaxis of first variceal bleeding in patients with cirrhosis. Journal of Gastroenterology and Hepatology 2006; 21: 413-416.
11.Ala I. Sharara, Don C. Gastroesophageal Variceal Hemorrhage. N Engl J Med 2001; 345(21): 1580-1582.
12.Chung S. Management of bleeding in the cirrhotic patient. Journal of Gastroenterology and Hepatology 2002; 17: 355-360.
13.Terblaanche J. The management of portal hypertension: Controversies. Journal of Gastroenterology and Hepatology 2002; 17: 439-441.
14.Philip J, Classen M, Gunselmann W. European emergency endoscopy study, European Congress of Gastrointestinal Endoscopy 1980.
15.Silverstein FE, Gilbert DA, Tedesco FJ, et al. The national ASGE survey on upper gastrointestinal bleeding. II. Clincal prognostic factors. Gastrointest Endosc 1981; 27: 80-93.
16.Kohler B, Rieman JF. Upper gastrointestinal bleeding-valve and consequences of emergency endoscopy and endoscopic treatment. Hepato-gastroenterol 1991; 38: 198-200.
17.Stollman NH, Putcha RV, Neustater BR, et al. The uncleared fundal pool in acute upper gastrointestinal bleeding: implications and outcomes. Gastrointest Endosc 1997; 46(4): 324-327.
18.Wilcox CM, Clark WS. Causes and outcome of upper and lower gastrointestinal bleeding: the Grady Hospital experience. South Med J 1999; 92(1): 44-50.
19.Golanova J, Hrdlicka L, St'ovicek J, et al. Acute hemorrhage of the upper part of the gastrointestinal tract--survey of emergency endoscopy of the upper gastrointestinal tract at our facility. Vnitr Lek 2004; 50(4): 259-261.
20.Thomopoulos KC, Vagenas KA, Vagianos CE, et al. Changes in aetiology and clinical outcome of acute upper gastrointestinal bleeding during the last 15 years. Eur J Gastroenterol Hepatol 2004; 16(2): 177-182.
21.Wiwaniflcit V. Overview of Clinical Reports on Urinary Schistosomiasis in the Tropical Asia. Pak J Med Sci 2005; 21(4): 499-501.
22.Said R, Hamzeh Y, Mehyar N, Rababah M. Hepatitis C virus infection in hemodialysis patients in Jordan. Saudi Medical Journal 2003; 24 (7): 137-138.
23.Ossama a, Serebour FE, AlDrees AZ, et al. Hepatitis C virus seroprevalence rate among Saudis. Saudi Medical Journal 2003; 24 (7): 81-86.