Evaluating and managing GI bleeding in the elderly: atypical presentations can complicate the workup

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Date: May 2003
From: The Journal of Critical Illness(Vol. 18, Issue 5)
Publisher: CMP Medica, LLC
Document Type: Article
Length: 5,024 words

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ABSTRACT: Upper and lower GI bleeding is a common cause of morbidity and mortality in the elderly. The presentation of GI bleeding may range from anemia in the absence of specific GI symptoms to massive, life-threatening bleeding. In the elderly, visual and cognitive impairment can obscure the clinical presentation; comorbidities and polypharmacy may complicate management and contribute to poor outcome. Patients who experience a major upper bleed require immediate hemodynamic stabilization. Advantages of early endoscopy include increased diagnostic accuracy; shortened hospitalization, and reduced risk of rebleeding. For patients with lower GI bleeding, sigmoidoscopy or colonoscopy is recommended to rule out anorectal pathology. Special precautions to observe in the elderly include anticoagulation management and close monitoring during procedures to avoid prolonged apnea or aspiration of gastric contents. (J Crit Illness. 2003;18(5):227-236)

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As the percentage of elderly persons in our population continues to expand, physicians will increasingly be called on to manage their health care needs. The problem of upper and lower GI bleeding is no exception. The aging process itself, combined with the stresses of comorbidity and multiple medications, sets the stage for the development of certain bleeding lesions, such as diverticulosis. Moreover, GI bleeding is associated with higher rates of morbidity and mortality in the elderly than in younger patients.

Sources of GI bleeding in the elderly include those seen in younger patients (for example, peptic ulcer), as well as some that are unique to this population (such as diverticulosis and angiodysplasia). In the elderly, as in the young, the clinical presentation may vary from anemia in the absence of specific GI symptoms to massive, life-threatening bleeding. Certain disorders, however, present atypically in older persons. This, combined with alterations in pain perception that occur with aging, makes the evaluation and management of GI bleeding a special challenge in older patients. (1,2)

In this article, we discuss the unique features--and common causes--of upper and lower GI bleeding in the elderly (except for the special problem of a positive fecal occult blood test in asymptomatic persons). We also address important management issues, such as hemodynamic resuscitation; anticoagulation; and medical, surgical, and endoscopic therapy. For the purposes of this article, we define "elderly" as older than 60 years.

UPPER GI BLEEDING

Approximately 35% to 45% of all cases of acute upper GI hemorrhage occur in elderly persons. (3) These patients increasingly account for the 10% of deaths that result from a bleeding episode each year. (4) This trend cannot be explained solely on the basis of demographic changes. Lack of a substantial decline in mortality suggests that the improved survival resulting from advances in diagnosis, monitoring, and treatment is being offset by the increase in the number of high-risk elderly patients in our population.

Causes and course of illness

The causes of acute upper GI bleeding in elderly patients are listed in Table 1. The incidence of peptic ulcer disease is similar for elderly and young persons. However, problems related to alcohol abuse--Mallory-Weiss tears, gastroesophageal varices, and gastropathy--are less common in elderly than...

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Gale Document Number: GALE|A102540063