Upper Gastrointestinal Bleeding in the Aged: A Prospective Study Utilizing a Younger Age Group as Control

DAVID KATZ, M.D., DANIEL PAULO, M.D.,

WH.LIAM M. P. I"~{cKINNON, M.D., and GEORGE B. JERZr GLASS, M.D.

A REVIEW Of the l i terature reveals a relative paucity of reports dealing with the problem of sources of gastrointestinal bleeding in the aged

and an absence of prospective studies dealing with the subject in indi- viduals above the age of 60. T h e retrospective studies available, carrying with thenl the inherent failings of chart surveys, are derived to a great extent from surgical and necropsy material. I t was felt that a prospective study at a municipal teaching center of all patients admit ted for upper gastrointestinal hemorrhage, comparing findings for patients above and below the age of 60, would help clarify differences (if any) in etiology, severity, and outcome in the two groups.

T h e prospective study was begun in December 1961, and extended through March 1964, dur ing which time, evaluations were made of 100 consecutive upper gastrointestinal bleeding episodes in patients above the age of 60. During the same period, 181 similar episodes were encountered in patients below the age of 60. These cases served as our control ma- terial.

P R O C E D U R E S AND R E S U L T S

All patients with histories of hematenlesis or melena within the 24-hr. period prior to admission were inch, ded in the study, as were all patients whose acute episodes of upper gastrointestinal bleeding commenced dur- ing hospitalization. Ice-water lavage followed by immediate esophagos- copy and gastroscopy was performed as an emergency procedure or dec-

From the Section of Gastroenterology, Department of Medicine, and the Department of Surgery, New York Medical College-Metropolitan ttospital Medical Center, New York, N. Y.

Supported in part by Clinical Research Center Grant AM-05576-03 from the National Institute of Arthritis and Metabolic Disease, U. S. Public Health Service, and by Con- tract U-1373 from the Health Research Council of the City of New York, New York, N.Y.

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tively within the first 16 hr. of admission, according to our previously reported criteria. 1-a Upper gastrointestinal X-ray fihns were taken 2 4 4 8 hr. after endoscopy, as a general rule. Endoscopic diagnosis of the source of bleeding was established only if bleeding was seen f rom a lesion or a clot seen therein. I f endoscopy revealed no bleeding site in the esophagus or proximal stomach, and a distal lesion was demonstrated by X-ray, the latter was accepted as the bleeding source. No diagnosis was acceptable on clinical grounds alone.

As in previous communicat ions dealing with the problem of upper gastrointestinal bleeding, 1--a we arbitrari ly classified "massive bleeders" into 3 groups. Group 1 included all patients with hemoglobin levels below 8.5 gm.~o on admission. Group 2 included all patients requir ing 2000 cc. of blood within 24 hr. of admission. Group 3 included patients fulfilling both criteria.

BLEEDING SOURCES Upper GI Bleeding

T h e bleeding sources in all 281 cases are listed in Tab l e 1. Erosive gas- tritis and duodenal ulcer were the leading sources of bleeding in the

TABLE 1. SOURCES OF UPPER GI H E M O R R H A G E

Patients over 60 Patients under 60

Diagnosis No. % No. %

Erosive gastritis 23 23.0 33 18.2 Duodenal ulcer 21 21.0 33 18.2 Esophageal varices 13 13.0 38 21.0 Gastric ulcer 7 7.0 19 10.5

Acute 4 4.0 12 6.6 Chronic 3 3.0 7 3.9

Multiple diagnoses 5 5.0 5 2.8 Gastric carcinoma 6 6.0 0 0 Hiatus hernia 2 2.0 3 1.7 Marginal ulcer 0 0 3 1.7 Miscellaneous 4 4.0 10 5.5

Esophageal carcinoma 0 0 1 .5 Gastric varices 0 0 1 .5 Menetrier 's disease 0 0 1 .5 Gastric leiomyoma 1 1.0 1 .5 Dental extraction 0 0 1 .5 Mallory-Weiss 0 0 2 1.I Gastric volvulus 1 1.0 0 0 Esophageal ulcer 0 0 3 1.7 Weber-Osler-Rendu 1 1.0 0 0 Gastric leiomyosarcoma 1 1.0 0 0

Unknown 19 19.0 37 20.4

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group over 60. Esophageal varices, erosive gastritis, and duodenal ulcer were the leading causes of bleeding in the group under 60.

As indicated previously, ~-3 the acute gastric lesion (acute erosive gas- tritis and /o r acute gastric ulcer) is the leading source of bleeding at our hospital. Thus an acute gastric lesion accounted for 27% of the bleeding episodes in the older group and for 24.6% in the younger group. Chronic peptic ulcer (duodenal, chronic gastric, or marginal) was the bleeding source in only 24% of those over 60 and 23.8% of those under 60.

Aside from the difference in the incidence of bleeding due to esopha- geal varices (13% in the older group vs. 21% in the younger) , and the absence of gastric carcinoma as a bleeding source in those below 60 (as compared with a 6% incidence in those above 60), there were no appre- ciable differences between the 2 over-all groups.

Massive Bleeding Episodes

In patients over 60, duodenal ulcer was the major source of bleeding without regard to criteria for evaluation of massive bleeding (Table 2). Erosive gastritis was the second leading source in Group 1, while esopha-

TABI.E 2. SOURCES OF MASSIVE UPPER GI H E M O R R H A G E

Group 1 Group 2 Group 3

Diagnosis No. % No. % No. %

PATIENTS OVER 60

Esophageal varices 9 13.4 9 21.4 7 21.2 Erosive gastritis 10 15.0 6 14.2 3 9.0 Duodenal ulcer 20 30.0 12 28.5 11 33.3 Gastric ulcer 6 90 3 7.1 1 3.0

Acute 3 4.5 1 2.3 0 0 Chronic 3 4.5 2 4.7 t 3.0

Gastric carcinoma 5 7.5 3 7.1 3 9.0 Miscellaneous 5 7.5 1 2.3 1 3.0 Unknown 11 16.6 8 19.0 7 21.2

TOTAL 66 100.0 42 100.0 33 100.0

PATIENTS UNDER 60

Esophageal varices 24 31.6 Erosive gastritis 6 7.9 Duodenal ulcer 11 14.5 Gastric ulcer 12 15.8

Acute 9 11.8 Chronic 3 3.9

Miscellaneous 7 9.2 Unknown 16 21.1

TOTAL 76 100.0

24 36.9 15 34.0 6 9.2 6 13.6

16 24.6 7 15.9 7 10.8 6 13.6 3 4.6 3 6.8 4 6.2 3 6.8 7 10.8 6 13.6 5 7.7 4 9.1

65 100.0 44 100.0

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geal varices ranked second in Groups 2 and 3. In patients under 60, esophageal varices were the leading source of bleeding, followed by duo- denal ulcer as the second most frequent by all criteria.

Of the older patients, 66% entered with hemoglobin levels below 8.5 gm.%, contrasted with 42% of the younger patients. T h e difference is statistically significant (p < .05). There was no significant difference between the groups in need for transfusion; 42% of the older group needed 2000 cc. of" whole blood within the first 24 hr., as did 36% of the younger patients. Group 3 included 33% of the older patients and 27% of the younger; there was no significant difference.

Th e difference in hemoglobin levels at admission may simply reflect pre-existing anemia in some of the older patients.

It is seen that a patient over 60 whose bleeding is massive (as ascer- tained by his classification in Group 3) most probably bleeds from duo- denal ulcer (33.3%) or esophageal varices (21.2%). An acute gastric lesion and gastric cancer each causes 9% of the massive bleeding episodes. In contrast, a massively bleeding patient under 60, judged by the same criteria, most frequently bleeds from esophageal varices (34%) or an acute gastric lesion (20.4%). Duodenal ulcer is the source only 15.9% of the time. Thus, duodenal ulcer is the source of massive bleeding epi- sodes twice as frequently in the aged as in the young, a point which, to our knowledge, has never been stressed previously. This difference is statistically significant at the 6% level (p = .06). Conversely, varices are a more frequent source of massive bleeding episodes in patients un- der 60 than over 60 (34% vs. 21.2%) ; the difference, however, is statis- tically not significant (p = .43).

Nonmassive Bleeding Episodes

Erosive gastritis was by far the major source of moderate or light bleed- ing in those over 60 (Table 3). In the aged patients bleeding nonmas- sively, the incidence of duodenal ulcer was only half that of erosive gas- tritis. In those under 60, erosive gastritis, duodenal ulcer, and esopha- geal varices were the leading sources with nearly equal incidences.

Erosive gastritis is strikingly more frequent as the source of nonmassive bleeding episodes in patients over 60 than duodenal ulcer. This may be related to the intake of salicylates and other medications in older patients suffering from osteoarthritis. 1, 2

MORTALITY

A breakdown of mortality according to diagnosis is provided Table 4.

in

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T A B L E 3. SOURCES OF NONMASSIVE U P P E R GI H E M O R R H A G E

Patients over 60 Patients 'under 60

Diagnosis No. % No. %

Erosive gastri t is 20 29.8 27 19.7 Duodena l ulcer 10 14.9 26 18.9 Esophageal varices 6 8,9 23 16.8 Gastric ulcer 6 8.9 13 9.5

Acute 4 5.9 9 6,6 Chronic 2 3.0 4 2.9

Mul t ip le diagnoses 5 7.4 4 2.9 Gastr ic carc inoma 3 4.5 0 0.0 H ia tus h e r n i a 2 3.0 3 2.2 Margina l ulcer 0 0,0 2 1.5 Miscel laneous 3 4.5 6 4.4

Gastr ic l e iomyoma 1 1.5 1 0.8 Mallory-Weiss 0 0,0 2 1.5 Gastric volvulus 1 1.5 0 0.0 Esophageal ulcer 0 0.0 3 2.2 Weber -Os le r -Rendu t 1,5 0 0.0 U n k n o w n 12 17.9 33 24.1

TOTAL 67 100.0 137 100.0

The Aged Group

During the period of hospitalization initiated by the bleeding episode, 28 of the 100 patients above 60 died. Using the criteria for Group 3 as the sole indicators of massive bleeding, the mortality figures were 13 of 33 (39.4%) in the massively bleeding group, and 15 of 67 (22.3.%) in the group of nonmassive-bleeding patients.

The Younger Group

Of those under 60, 37 (20.5%) died. In the massively bleeding group, 15 of 44 patients (34.1%) died, as compared with 22 of 137 patients (16.1%) in the nonmassive group. Comment Striking is the absence of statistically significant differences in over-all mortality (p < .30). However, significant differences in mor- tality are noted when varions diagnoses are considered. Duodenal ulcers bleeding nonmassively in patients over 60 cause a significantly greater mortality than in patients under 60 (p < .01) ; so do esophageal varices bleeding nonmassively and over-all esophageal varices, in the older and younger age groups, respectively (p < .05 for both). There was no statistically significant difference between the 2 age groups in mortality from any other cause of bleeding. A striking difference in mortality, with statis,tical significance at the 6% level (p = .06), is seen in massively bleed-

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TABLE 4. MORTALITY IN ACUTE UPPER GI HEMORRHAGE

Over-all Nonmassive Massive

Diagno,sis No. Died % No. Died % No. Died ~,o

PATIENTS OVER 60

Erosive gastritis 23 4 17.4 20 3 15.0 3 1 33.3 Duodenal ulcer 21 4 19.0 10 3 30.0* 11 1 9.1 Esophageal varices 13 8 61.5" 6 4 66.7* 7 4 57.0 Acute gastric ulcer 4 0 00 4 0 0.0 0 0 0.0 Chronic gastric ulcer 3 0 0.0 2 0 0.0 l 0 00 Miscellaneous I7 7 41.2 13 4 30.7 4 3 75.0 Unknown 19 5 26.3 12 1 8.3 7 4 57.0

To'rAL 100 28 28,0 67 15 22.3 33 13 39.4

PATIENTS UNDER 60

Erosive gastritis 33 5 15.1 27 4 14.8 6 1 16.7 Duodenal ulcer 33 4 12,2 26 1 3,9" 7 3 42.9 Esophageal varices 38 13 34.2* 23 7 30.4* 15 6 40.0 Acute gastric ulcer 12 1 8.3 9 0 0,0 3 1 33.3 Chronic gastric ulcer 7 4 57.0 3 2 66.7 4 2 50.0 Miscellaneous 21 3 14.3 15 1 6.7 6 2 33.3 Unknown 37 7 18.9 34 7 20.6 3 0 0.0

TOTAL 181 37 20.5 137 22 16,1 44 15 34.1

*Statistically significant difference between the 2 age groups (p% .05).

ing d u o d e n a l ulcers. T l l e lower mor ta l i ty in the older g roup p robab ly reflects the success of an aggressive approach to surgery in the aged.

DISCUSSION

T a b l e 5 shows a relat ively large compi la t ion of reports of b leed ing episodes in pa t ients above the age of 60. Palmer , 4 u t i l i z ing early endos- copy, saw only 99 b leed ing episodes in pa t ien ts over 60 and 551 in pa- t ients u n d e r 60. He repor ted a s imilar ly low inc idence of d u o d e n a l ulcer (28.2%), bu t d iagnosed chronic gastric ulcer a nd erosive esophagitis

more f requen t ly t han we did, and the acute gastric lesion less often. Rely- ing u p o n necropsy mate r ia l a lone in pa t ients who had had massive bleed-

ing, Kane e t al.~ demons t ra t ed d u o d e n a l n icer to have been the source of b leed ing 26.9% of the t ime in pa t ients over 60, esophageal varices 12.8%, a n d an acute gastric lesion 7.6%. These f indings are s imi lar to those no ted in our G r o u p 3 of massive bleeders, as is the 6% incidence of gastric ca rc inoma repor ted by Kane et al. Again, these investigators

diagnosed gastric ulcer at autopsy signif icantly more (31.8%) than

we did. F r anke l and T r u e l o v e ~ omi t ted rou t ine early endoscopy, bu t in a clini-

cal s tudy of b leed ing in the aged still demons t ra t ed a 16.6c~o incidence of

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T A B L E 5. SOURCES OF U P P E R GI H E M O R R H A G E IN T I l E AGED (SURVEY OF L I T E R A T U R E )

Kane et al? Ben~elt and Flaukel and Present

Palmer~ Whiteside 7 Truelove ~ study

Diagnosis No. % No. % No. % No. % No. %

Acute gastric lesion 18 7.6* 8 8,17 3 3.2"i" 38 16.6" 27 275 Duodena l ulcer 63 26.9 28 28.2 35 38.0 148 64.6§ 2t 21 Esophageal varices 30 12.8 17 17.2 8 8,7 10 4.4 13 13 Chronic gastric ulcer 74 31.8 15 15.2 19 20.6 - - - - 3 3 Gastric carcinoma 15 6.4 0 0.0 0 0.0 13 5.7 6 6 Miscellaneous 34 14.5 21 21.211 12 13,0 8 3,5 1l 11 U n k n o w n 0 0.0 10 10.1 15 16.2 12 6.2 19 19

TOV.~L 234 100.0 99 100.0 92 100.0 229 100.0 100 100

*Acute gastric ulcer "iAcute erosive gastritis + 9 - +.3 cases of erosive gastritis; 4, acute gastric ulcer §Chronic peptic ulcer w i thou t subdivision into duodena l or gastric t lIncluded 14 cases (14.2%) of erosive esophagitis.

acute gastric ulcer as the source of bleeding. T h e incidence of variceal bleeding (4.4%) was low, as usually reported in English series. T h e com- bined incidence of duodenal and gastric ulcer was 64.6%, the low (5.2%) incidence of undiagnosed cases suggesting that clinical criteria were used for the diagnosis. Bennett and Whiteside, z repor t ing on 92 surgical patients above the age of 65, demonstrated a low incidence of duodenal ulcer (38%) as a source of bleeding. No endoscopy was performed.

Our 28% mortal i ty in the aged group compares with the 29% noted by Welch s in patients over 60 bleeding f rom upper gastrointestinal lesions. Welch, however, noted a significant difference in mortal i ty be- tween tlle younger and older groups. In his series of 363 patients, 29% of those above 60 died, as compared with 8% of those below 60. Lewison 9 noted no significam differences in mortality, compar ing bleeding epi- sodes in patients with duodenal ulcer above and below the age of 50, a conclusion which held true in our study, in which the age of 60 was used as the limit line.

As reported previously, ~-~ the endoscopic technic was well tolerated and no morbidi ty or mortal i ty derived therefrom. T h e 3 oldest patients, one 97 and two over 90, tolerated the procedure equally as well as pa- tients in any other age group.

In our experience with patients oxer 60, endoscopy demonstrated the source of bleeding in 52% of the cases, while X-ray was able to demon- strate the source in only 22 of the 100 patients. Under op t imum condi- tions, in our experience, ~ the cause of bleeding can be diagnosed by X-ray

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in less than 39% of cases. This again calls attention to the innate short- comings of reports which purport to show sites of bleeding and in which X-ray alone is utilized as a diagnostic tool.

S U M M A R Y

1. Consecutive patients admitted for acute upper gastrointestinal bleeding were investigated by means of early esophagogastroscopy and upper gastrointestinal X-ray over a period exceeding 3 years. The series included 100 patients above the age of 60 and 181 below 60.

2. An acute gastric lesion (erosive gastritis or acute gastric ulcer) was the leading over-all source of bleeding in patients over and under 60 (27.0% and 24.8%, respectively). In nonmassive bleeding episodes, an

acute gastric lesion was again the leading source in both groups (35.7,°-/0 and 26.3%, respectively).

3. In massive bleeding, duodenal ulcer was the leading source in those over 60 (33.3%), while esophageal varices was the leading cause of bleed- ing in those below 60 (34.0%).

4. No statistically significant difference was noted in the severity of bleeding episodes in the over- and under-60 groups, nor was there any statistically significant difference in the over-all mortality of the 2 groups.

5. Early esophagogastroscopy was both safe and significant in estab- lishing the sources of bleeding in the old age group.

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REFERENCES

]. KATZ, D., DOUVRES, 1)., WEISBERG, H., MCKINNON, W. M. P., and GLASS, G. B. J. Early endoscopic diagnosis of acute upper gastrointestinal hemorrhage, J.A.M.A. 108:405, 1964.

2. KATZ, D., DOUVRES, P., WEISBERG, H., CHARM, R., and McKINNON, W. M. P. Sources of bleeding in upper gastrointestinal hemorrhage: A re-evaluation. Am. J. Dig. Dis. 9:447, 1964.

3. KATZ, D., DOUVRES, I)., X¥EISBERG, H., CHARM, R., and McKINNON, W. M. 19. Endo- scopic experience with 281 consecutive cases of tipper gastrointestinal hemorrhage. Bull. Am. Soc, G. I. Endoscopy. February t96,5.

4. PALMr~, E. D. Diagnosis of Upper Gastrointestinal Hemorrhage. Thomas, Spring- field, 1961.

5. KANE, J. M., MEYER, K. A., and KOZEL, B. D. An anatomical approach to the prob- lem of massive gastrointestinal hemorrhage. A,M.A, Arch. Surg. 70:570, 1955

6. FRANKEL, G. L., and TRUELOVE, S. C. Hematemesis in the elderly. J. Am. Geriat. Soc. 4:417, 1956.

7. BENNETT, J. M., and WHITESIDE, W. Acute upper gastrointestinal hemorrhage in patients over 65 years of age. A.M.A. Arch. Surg. 81:504, 1960.

8. WELCH, C. E. Treatment of acute massive gastroduodenal hemorrhage. ].A.M.A. 141:1113, 1949.

9. LEWISON, E. 1~. Bleeding peptic ulcer. Internat. Abstr. Surg. 109:I, 1950.

696 American ,Journal of Digestive Diseases