Acute lower gastrointestinal hemorrhages in geriatric patients

Survival Analysis of Geriatric Patients with Low Digestive Hemorrhage Attending an Emergency Department

BACKGROUND

The increase in life expectancy and low mortality have doubled the number of individuals older than 65 in the last 30 years.

METHODS

We conducted a retrospective study of 101 patients older than 80 years of age treated by low digestive hemorrhage (LDH) in an emergency department during 2018. Sociodemographic variables were evaluated, as well as comorbidity and survival at 18 months. Survival was assessed by a Kaplan-Meier test.

RESULTS

52.5% of the subjects were women. The average comorbidity of the sample was 1.97. The survival rate per year was 60%. The finding on colonoscopy shows no association with mortality. However, those patients on anticoagulant/antiplatelet therapy have a higher survival rate.

CONCLUSION

Survival per year is high, so urgent colonoscopy for an LDH should be performed after evaluating the patient's stability and functional status in a scheduled and outpatient manner.

Acute lower gastrointestinal haemorrhage: outcomes and risk factors for intervention in 949 emergency cases

PURPOSE

Outcomes of acute lower gastrointestinal haemorrhage (ALGIH) are mostly derived from studies performed in the sub-acute/elective rather than the emergency department (ED) setting. The aims of this study were to determine the incidence and outcomes of patients presenting to a tertiary hospital ED with ALGIH and to identify associated clinicopathological risk factors.

METHOD

A retrospective observational cohort study of consecutive patients presenting with ALGIH to a tertiary hospital ED was performed. Primary outcome measures included mortality and hospital (including high dependency [HDU]) admission. Secondary outcome measures included rates of (i) blood transfusion, (ii) radiological/endoscopic investigation(s) and (iii) therapeutic intervention.

RESULTS

ALGIH accounted for 949 (512 M, mean age 62.3 years) of 130,262 (0.73%) ED presentations, of which 285 patients (30.1%) were on anti-platelet/coagulant therapy. There were five deaths (0.5%). Hospital admission was required in 498 patients (52.5%), of which 19 (3.8%) required HDU monitoring. Hospital admission was twice as likely in males and four times more likely in patients >75 years old and those taking multiple anti-platelet/coagulant therapy (P < 0.05). Blood product transfusion was required in 172 patients (34.5%), specialist investigations in 230 (46.2%) and therapeutic intervention in 51 (10.2%) (surgery in 24 [4.8%]; endoscopic haemostasis in 20 [4.0%] and angiographic embolisation in 9 [1.8%] patients).

CONCLUSION

ALGIH accounts for 1% of all ED presentations, with half requiring hospital admission. Mortality and surgical intervention rates are low and although most patients can be managed supportively, access to interventional radiology/endoscopy is important.

Aspirin and non-aspirin NSAIDs increase risk of colonic diverticular bleeding: a systematic review and meta-analysis

Lower gastrointestinal bleeding is a frequent cause of hospitalization, particularly in the elderly, and its incidence appears to be on the rise. Colonic diverticular bleeding is the most common form of lower gastrointestinal bleeding and is responsible for 30-40 % of bleeding episodes. Risk factors associated with diverticular bleeding include obesity, hypertension, anticoagulants, diabetes mellitus, and ischemic heart disease. Recent studies have suggested a relationship between usage of non-steroidal anti-inflammatory drugs (NSAIDs) and colonic diverticular bleeding; however, most studies were small with wide confidence intervals. We identified studies by searching the PubMed and Scopus databases (from inception through 31 December 2012) and by searching bibliographies of relevant articles. Summary relative risks (RRs) with 95 % confidence intervals (CIs) were calculated with fixed-effects and random-effects models. A total of six studies (five case-control studies and one cohort study) met inclusion criteria for analysis. Non-aspirin NSAIDs (NANSAIDs) and aspirin were associated with an increased risk of colonic diverticular bleeding (summary RR = 2.48, 95 % CI 1.86-3.31), with moderate heterogeneity among these studies (P heterogeneity = 0.11, I (2) = 44.4 %). Stratification to evaluate the heterogeneity found that both NANSAIDs (summary RR = 2.24, 95 % CI 1.63-3.09; 5 studies) and aspirin (summary RR = 1.73; 95 % CI 1.31-2.30; 3 studies) were associated with the risk of diverticular bleeding. Aspirin/NANSAIDs use was strongly and consistently associated with an increased risk of colonic diverticular bleeding. Further studies are needed to stratify individuals at risk of diverticular bleeding associated with the use of these agents.

Pros and cons of colonoscopy in management of acute lower gastrointestinal bleeding

Acute lower gastrointestinal bleeding (LGIB) is a frequent gastrointestinal cause of hospitalization, particularly in the elderly, and its incidence appears to be on the rise. Endoscopic and radiographic measures are available for the evaluation and treatment of LGIB including flexible sigmoidoscopy, colonoscopy, angiography, radionuclide scintigraphy and multi-detector row computed tomography. Although no modality has emerged as the gold standard in the management of LGIB, colonoscopy is the current preferred initial test for the majority of the patients presenting with hematochezia felt to be from a colon source. Colonoscopy has the ability to diagnose all sources of bleeding from the colon and, unlike the radiologic modalities, does not require active bleeding at the time of the examination. In addition, therapeutic interventions such as cautery and endoclips can be applied to achieve hemostasis and prevent recurrent bleeding. Studies suggest that colonoscopy, particularly when performed early in the hospitalization, can decrease hospital length of stay, rebleeding and the need for surgery. However, results from available small trials are conflicting and larger, multicenter studies are needed. Compared to other management options, colonoscopy is a safe procedure with complications reported in less than 2% of patients, including those undergoing urgent examinations. The requirement of bowel preparation (typically 4 or more liters of polyethylene glycol), the logistical complexity of coordinating after-hours colonoscopy, and the low prevalence of stigmata of hemorrhage complicate the use of colonoscopy for LGIB, particularly in urgent situations. This review discusses the above advantages and disadvantages of colonoscopy in the management of acute lower gastrointestinal bleeding in further detail.

Therapeutic and interventional endoscopy for gastrointestinal bleeding

INTRODUCTION

Gastrointestinal (GI) bleeding remains a common clinical problem encountered by every emergency room and trauma physician. Endoscopy remains the main approach to the diagnosis and therapy of GI bleeding.

OBJECTIVES

To present the modern endoscopic approach for GI bleeding.

METHODS

Narrative review based on our expertise and inclusion of classic articles dealing with interventional and therapeutic GI endoscopy.

RESULTS

GI hemorrhage is now classified as upper, middle, and lower GI bleeding. Upper GI bleeding is defined as hemorrhage originating from the oropharynx to the ligament of Treitz (or papilla of Vater), middle GI bleeding occurs distal to the papilla of Vater to the terminal ileum, and lower GI bleeding is defined as bleeding distal to the ileocecal valve, including the entire colon and anorectum. Endoscopic methods used to diagnosed and treat GI bleeding include esophagogastroduodenoscopy, duodenoscopy, capsule endoscopy, double- and single-balloon enteroscopy, spiral enteroscopy, and colonosocopy.

CONCLUSIONS

This is the first review paper dedicated to endoscopic therapy for bleeding involving any part of the luminal GI tract (i.e., esophagus, stomach, small bowel, and colon). Modern endoscopy permits the investigation and treatment of the majority of conditions affecting the entire hollow GI tract.

Risk factors predictive of severe diverticular hemorrhage

BACKGROUND

Diverticular disease is a common cause for lower gastrointestinal bleeding. Although the hemorrhage often resolves spontaneously, some patients will require massive transfusions and emergency surgery. In this study we report risk factors predictive of severe diverticular bleeds.

METHODS

We completed a retrospective analysis of 99 patients, admitted with lower gastrointestinal bleeding and colonoscopic evidence of diverticulosis and no other cause of the hemorrhage between January 1995 and December 2005. A database was generated and univariate and multivariate analyses were carried out.

RESULTS

Of the 99 patients, 23 patients were classified as having a severe bleed defined as having a systolic blood pressure below 90 mm Hg, requirement for more than 6 units of transfusion, or emergent surgery. Multiple logistic regression showed that the initial hemoglobin (p = 0.001), INR ≥ 1.5 (p = 0.003), initial diastolic blood pressure (p = 0.024), initial heart rate (p = 0.047), and blood pressure medications (p = 0.049) predicted severe diverticular hemorrhage.

CONCLUSIONS

The identified predictor variables are all quantifiable at the time of initial presentation, and these may help identify severe cases of diverticular bleeding requiring urgent management.

Lower gastrointestinal bleeding in the elderly

Lower gastrointestinal bleeding (LGIB) is an important worldwide cause of morbidity and mortality in the elderly. The incidence of LGIB increases with age and corresponds to the increased incidence of specific gastrointestinal diseases that have worldwide regional variation, co-morbid diseases and polypharmacy. The evaluation and treatment of patients is adjusted to the rate and severity of hemorrhage and the clinical status of the patient and may be complicated by the presence of visual, auditory and cognitive impairment due to age and co-morbid disease. Bleeding may be chronic and mild or severe and life threatening, requiring endoscopic, radiologic or surgical intervention. Colonoscopy provides the best method for evaluation and treatment of patients with LGIB. There will be a successful outcome of LGIB in the majority of elderly patients with appropriate evaluation and management.

[Severe lower gastrointestinal tract bleeding due to diverticulosis]

INTRODUCTION

Diverticulosis is the most frequent cause of lower gastrointestinal (GI) bleeding in adults in western countries. The aims of the present study were to analyze: 1) the diagnostic and therapeutic management of patients with severe lower GI bleeding due to diverticulosis; 2) associated morbidity and mortality; 3) the need for surgery, and 4) bleeding recurrence rates after hospital discharge.

MATERIAL AND METHODS

Were retrospectively reviewed 42 patients with severe lower GI bleeding due to diverticulosis. Patients with rectorrhagia requiring transfusion of at least three packed red blood cell units and those with a decrease in hematocrit of 10 points or more were included. As a control group, we used 133 patients with severe lower GI hemorrhage due to causes other than colonic diverticular disease.

RESULTS

All patients were stabilized with conservative measures except one who required emergency surgery. Colonoscopy was performed in 39 patients and the most frequent finding consisted of recent signs of bleeding independently of whether colonoscopy was performed early or was delayed. Endoscopic treatment with Argon laser electrocoagulation was performed in one patient. Bleeding recurrence after hospital discharge occurred in 13 patients (31%); of these, seven (16%) required hospital readmission.

CONCLUSION

Severe lower GI bleeding due to diverticulosis can usually be resolved with conservative treatment although the percentage of bleeding recurrence is high. Early endoscopy is not as important as in the remaining causes of severe lower GI bleeding.

Management of lower gastrointestinal bleeding after colorectal resection and stapled anastomosis

BACKGROUND

Although limited haematochezia with the first bowel movement is frequent in patients undergoing colorectal resection, postoperative life-threatening lower gastrointestinal bleeding is very rare. The purpose of this study was to review our results in the management of this complication.

METHODS

We analysed the cases of patients with severe lower gastrointestinal bleeding after colorectal surgery from 2000 to 2006 in our hospital. We studied the general characteristics, diagnostic data, therapeutic management and outcome. We also reviewed the published articles regarding this issue.

RESULTS

This complication appeared in 7 (0.5%) of 1,389 colorectal procedures in the study period. In all the patients the anastomosis was stapled. In six of the seven patients bleeding resolved with conservative treatment including endoscopy. However, one patient required surgical treatment. There was no mortality and there were no anastomotic leaks in these seven patients.

CONCLUSION

Severe lower gastrointestinal bleeding after colorectal resection and stapled anastomosis is a rare complication. Only in unstable patients or failure of conservative measures is surgery indicated.

Gastrointestinal bleeding in the elderly

Gastrointestinal bleeding affects a substantial number of elderly people and is a frequent indication for hospitalization. Bleeding can originate from either the upper or lower gastrointestinal tract, and patients with gastrointestinal bleeding present with a range of symptoms. In the elderly, the nature, severity, and outcome of bleeding are influenced by the presence of medical comorbidities and the use of antiplatelet medication. This Review discusses trends in the epidemiology and outcome of gastrointestinal bleeding in elderly patients. Specific causes of upper and lower gastrointestinal bleeding are discussed, and recommendations for approaches to endoscopic diagnosis and therapy are given.

[Management of rectorrhagia having uncertain origin]

Rectorrhagia is a very frequent reason for hospital and Primary Health Care medical visits. Its main problem is that it is made up of a very heterogeneous group of patients and a correct diagnosis is difficult to make. The main diagnostic test is the colonoscopy, and in severe cases, the arteriography. When these examinations do not provide the diagnosis, small intestine disease should be suspected. In most of the cases, rectorrhagia abates spontaneously or is controlled with conservative measures, and the subsequent treatment with depend on the etiology that caused the bleeding. The great problem arises in 0.5%-4% of rectorrhagies that do not abate and unstabilize the patient, emergency surgery due to the bleeding being required.

Neue Epidemiologie der akuten gastrointestinalen Blutung

Due to progress in general medicine and especially in gastroenterology, the incidence of acute gastrointestinal hemorrhage could be expected to have decreased during the last 25 years. However, published epidemiological data cannot, in general, fulfill this hope. The interpretation of potential trends is, however, often limited by low study quality. For example, questionable bleeding sources such as erosions in the upper gastrointestinal tract or colon diverticula are often rather uncritically named the definitive causes of bleeding. However, there is clear evidence of changes in grouping of patients. After the almost complete disappearance of Helicobacter pylori in younger indigenous populations of most industrialized countries, it is mostly elderly comorbid people with additional risk factors (NSAID use, low-dose aspirin, anticoagulation) who are affected. Not unexpectedly, this group has generally experienced no change in incidence and in fact shows a deterioration of prognosis in case of acute bleeding.