Approach to upper gastrointestinal bleeding in the elderly

Approach to upper gastrointestinal bleeding in the elderly

Upper GI bleeding (UGIB) is bleeding proximal to the ligament of Treitz, presenting as haematemesis, coffee-ground vomiting, melaena, or occasionally haematochezia when brisk.

Pathy's places this in context: bleeding causes or contributes to the death of about 5% of the elderly population, chiefly from intracranial and subarachnoid haemorrhage, ruptured aortic aneurysm, and gastrointestinal bleeding from peptic ulcers and gastric or colonic malignancy.

A crucial principle: most bleeding in the elderly is localised and due to a specific underlying pathology, frequently malignancy — primary haemostatic disorders are relatively rare.

Peptic ulcer disease — the commonest cause; driven in older people by NSAIDs, aspirin, corticosteroids and H. pylori. Pathy's tabulates aspirin, NSAIDs (ibuprofen, diclofenac, naproxen) and corticosteroids as carrying an enhanced risk of peptic ulceration, and antiplatelets, DOACs, heparins and thrombolytics as carrying an enhanced risk of bleeding.

Erosive gastritis and duodenitis — drug-related and stress-related.

Oesophageal and gastric varices — in India a major cause, from cirrhosis and also from non-cirrhotic portal fibrosis and extrahepatic portal venous obstruction.

Oesophagitis, including pill oesophagitis — Pathy's notes perforation and bleeding as complications, particularly with potassium chloride, quinidine and non-steroidal drugs.

Malignancy — gastric and oesophageal carcinoma; must always be excluded in this age group.

Mallory–Weiss tear, Dieulafoy lesion, angiodysplasia, GAVE (watermelon stomach), aorto-enteric fistula after aortic graft.

Reduced physiological reserve — blunted tachycardic response (especially on beta-blockers), so hypotension appears late and shock is under-recognised.

Polypharmacy and antithrombotics — anticoagulants and antiplatelets both increase incidence and severity; warfarin effects are enhanced by age over 80, weight loss, acute illness, heart failure, renal and hepatic impairment.

Comorbidity — ischaemic heart disease limits tolerance of anaemia; CKD limits fluid loading; cirrhosis worsens coagulopathy.

Atypical presentation — syncope, falls, confusion, angina or breathlessness may be the only manifestation, with melaena discovered only on rectal examination.

ABC first: two wide-bore cannulae, crystalloid resuscitation, oxygen, protect the airway in active haematemesis or encephalopathy; hourly urine output and continuous monitoring.

Bloods: CBC, cross-match, urea and creatinine (a disproportionately raised urea supports an upper source), LFTs, coagulation profile, and consider troponin/ECG in older patients with ischaemic risk.

Risk stratification with the Glasgow–Blatchford Score (GBS): patients with GBS 0–1 are at very low risk of rebleeding, death or needing intervention and may be managed as outpatients. The Rockall score is used for post-endoscopic risk.

Transfusion: a restrictive strategy with a haemoglobin threshold of 7 g/dL is recommended in haemodynamically stable patients, targeting a post-transfusion haemoglobin of 7–9 g/dL. In those with acute or chronic cardiovascular disease, use a more liberal threshold of 8 g/dL.

Pre-endoscopic erythromycin: a single 250 mg intravenous dose 30–120 minutes before endoscopy improves visualisation, reduces the need for second-look endoscopy, reduces units transfused and shortens hospital stay.

Pre-endoscopic PPI: ACG could not reach a recommendation for or against it; in practice a high-dose PPI infusion is started while awaiting endoscopy and downgrades stigmata.

Antithrombotic management: withhold vitamin K antagonists; for haemodynamic instability give four-factor prothrombin complex concentrate (rapid onset) rather than routine FFP, which carries volume overload and TRALI risk. Do not routinely give vitamin K in acute bleeding because of slow onset and later difficulty re-anticoagulating. Do not routinely transfuse platelets. Do not stop aspirin used for secondary cardiovascular prevention — cessation increases 30-day mortality; if held, restart within 3–5 days. For dual antiplatelet therapy, continue aspirin and hold the second agent, restarting preferably within 5 days.

Tranexamic acid is not recommended in acute GI bleeding.

Timing: endoscopy within 24 hours of presentation for admitted patients. Very early endoscopy (<12 hours) may be considered with persistent haemodynamic instability, in-hospital bloody emesis, or when anticoagulation cannot be interrupted.

Forrest classification guides therapy: Ia spurting, Ib oozing, IIa non-bleeding visible vessel, IIb adherent clot, IIc flat pigmented spot, III clean base. Endoscopic therapy is indicated for Ia, Ib and IIa.

Endoscopic modalities: combination therapy (dilute adrenaline injection plus a second modality) — bipolar electrocoagulation, heater probe, absolute ethanol injection, clips, argon plasma coagulation, soft monopolar coagulation. Hemostatic powder spray (TC-325) is suggested for actively bleeding ulcers and over-the-scope clips for recurrent bleeding after previous successful haemostasis.

Post-endoscopic PPI: high-dose PPI continuously or intermittently for 3 days, then twice-daily oral PPI for the first 2 weeks after endoscopy.

Variceal bleeding: resuscitate, give terlipressin or octreotide plus prophylactic antibiotics (ceftriaxone), and perform endoscopic band ligation; consider early TIPS in high-risk patients. Gastric varices are treated with cyanoacrylate glue injection.

Failure of endoscopic therapy: repeat endoscopy for rebleeding; if this fails, transcatheter arterial embolisation is preferred to surgery in the elderly, with surgery reserved for uncontrollable bleeding or perforation.

Test for and eradicate H. pylori in all ulcer bleeding, and confirm eradication. Stop NSAIDs; if they are essential, co-prescribe a PPI or use a COX-2 inhibitor with PPI cover.

Re-evaluate the indication for every antithrombotic, restart at the earliest safe time with PPI co-prescription, and biopsy or repeat endoscopy for gastric ulcers to exclude malignancy.