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.     

Gastrointestinal bleeding in the elderly

Gastrointestinal bleeding in elderly individuals is a frequent cause of consultation with a physician and of hospital admissions. Co-morbidity and greater medication use in this steadily growing patient group influence the clinical course and adversely affect outcome. Clinical presentation is often predictable and guides subsequent patient management. Due to a surprising lack of prospective controlled data in the area of gastrointestinal bleeding, the selection of diagnostic and therapeutic manoeuvres often depends more on local expertise and availability than on an algorithmic approach. Advances in endoscopic, medical, radiological and surgical treatment modalities offer promising new diagnostic and therapeutic tools, particularly in concerted applications. Outcome studies on the appropriate sequence and linking of these modalities are urgently needed. This chapter will address clinical presentation, aetiology, diagnosis and treatment of both upper and lower gastrointestinal bleeding in the elderly.     

Gastrointestinal bleeding in the elderly.

Among patients with acute gastrointestinal bleeding, older age is associated with an increased rate of comorbidity, greater medication use, and atypical clinical presentations. The aging of the population makes the evaluation and management of gastrointestinal bleeding in the elderly a special and increasingly common clinical challenge. The unique features and common causes of upper and lower gastrointestinal bleeding in the elderly are reviewed. Important management issues considered include hemodynamic resuscitation; anticoagulation; and medical, surgical, and endoscopic therapy.     

Gastrointestinal bleeding in the elderly patient

The elderly patient with acute gastrointestinal bleeding requires a management approach that attends to age-dependent demands, such as functional status, the independent impact of functional status on outcomes such as short term mortality, and the consent process. This review examines issues such as patient triage, resuscitation, diet and medications, anticoagulation, endoscopy and conscious sedation, informed consent in the impaired patient, and discharge planning in light of these age-dependent demands.     

Gastrointestinal bleeding

Gastrointestinal bleeding encompasses a broad array of clinical scenarios. The spectrum is diverse because of the multiple types of lesions that can cause bleeding, and because bleeding can occur from virtually anywhere in the gastrointestinal tract. The fundamental tenets of management of patients with gastrointestinal bleeding include the following: (1) the patient must undergo immediate assessment and stabilization of hemodynamic status, (2) the source of bleeding must be identified, (3) active bleeding should be stopped, (4) the underlying abnormality should be treated, and (5) recurrent bleeding should be "prevented.     

Consecutive national surveys of ABO-incompatible blood transfusion in Japan

Background and Objectives  Morbidity and mortality from ABO-incompatible transfusion persist as consequences of human error. Even so, insufficient attention has been given to improving transfusion safety within the hospital.
Materials and Methods  National surveys of ABO-incompatible blood transfusions were conducted by the Japanese Society of Blood Transfusion, with support from the Ministry of Health, Labor and Welfare. Surveys concluded in 2000 and 2005 analysed ABO-incompatible transfusion data from the previous 5 years (January 1995 to December 1999 and January 2000 to December 2004, respectively). The first survey targeted 777 hospitals and the second, 1355 hospitals. Data were collected through anonymous questionnaires.
Results  The first survey achieved a 77·4% response rate (578 of 777 hospitals). The second survey collected data from 251 more hospitals, but with a lower response rate (61·2%, or 829 of 1355 hospitals). The first survey analysed 166 incidents from 578 hospitals, vs. 60 incidents from 829 hospitals in the second survey. The main cause of ABO-incompatible transfusion was identification error between patient and blood product: 55% (91 of 166) in the first survey and 45% (27 of 60) in the second. Patient outcomes included nine preventable deaths from 1995 to 1999, and eight preventable deaths from 2000 to 2004.
Conclusion  Misidentification at the bedside persists as the main cause of ABO-incompatible transfusion.     

Gastrointestinal bleeding in malaria

Hematological alterations are frequent in patients with malaria. However, these rarely manifest clinically, except for symptoms due to anemia. Two cases with gastrointestinal hemorrhage as a complication of malaria are reported.     

The role of blood transfusion in the management of upper and lower intestinal tract bleeding

Patients with gastrointestinal (GI) haemorrhage use 13.8% of all red blood cell transfusions in England. This review addresses the evidence for red blood cell, fresh frozen plasma and platelet transfusions in acute and chronic blood loss, from both the upper and lower intestinal tract. It reviews the indications for transfusion in GI bleeding, the haematological consequences of massive blood loss and massive transfusion, and the importance of managing coagulopathy in bleeding patients. It also looks at the safety and risks of blood transfusion, and provides clinicians with evidence to reduce unnecessary transfusion. Large controlled clinical trials of blood transfusion specifically in GI bleeding are required, along with further research into the use of adjuvant therapies such as recombinant activated factor VIIa. Changing clinician behaviour to reduce inappropriate blood transfusion remains a key target for future transfusion research.     

Gastrointestinal bleeding in infancy and childhood

Gastrointestinal (GI) bleeding is an alarming problem in children. Although many causes of GI bleeding are common to children and adults, the frequency of specific causes differs greatly, and some lesions, such as necrotizing enterocolitis or allergic colitis, are unique to children. This article reviews the spectrum of GI bleeding in infants and children. The causes, diagnostic evaluation, and management are discussed, and differences with adult medicine are highlighted.     

Gastrointestinal bleeding in marathon runners

Gastrointestinal bleeding has been proposed to be a contributing factor in the development of 'runner's anaemia'. To study the incidence of gastrointestinal bleeding, 2-3 prerace and 2-3 postrace faecal samples from 63 marathon runners were tested for the presence of blood. Five of the participants had faecal blood before but not after the race. A reasonable explanation for the bleeding was found for four. Eight runners (13%) had positive tests for faecal blood after the competition. Clinical investigation disclosed no gastrointestinal disease. Postrace haematuria was discovered in another 13% of the runners. None of the runners observed overt gastrointestinal bleeding or haematuria, nor did anyone develop anaemia. Gastrointestinal disturbances related to running were reported by 54%. It is concluded that gastrointestinal complaints and gastrointestinal bleeding are prevalent among marathon runners.     

Gastrointestinal bleeding in hookworm infection

Digestive Diseases and Sciences -