European Journal of Cardiovascular Medicine

Gastrointestinal bleeding (GIB) accounts for 1–2% of all acute hospital admissions and can manifest in five main ways: (a) hematemesis, (b) melena, (c) hematochezia, (d) occult bleeding, and (e) symptoms of blood loss or anemia, including light-headedness, angina, dyspnea, or syncope. [1]

Upper gastrointestinal bleeding (UGIB) is twice as common as lower gastrointestinal bleeding, with an incidence of 50–150 cases per 100,000 population per year. This incidence increases with age, often due to the misuse of non-steroidal anti-inflammatory drugs (NSAIDs) among the elderly. Males are affected at a rate twice that of females. The mortality rate from UGIB is 12–35% in patients over 60 years of age, less than 10% in those younger than 60, and the overall mortality rate ranges from 5–11%. [2]

Current population-based epidemiological data on UGIB trends in India are limited. Although peptic ulcer bleeding was once common, its prevalence has declined globally, as shown by various studies. [3]

Mortality from variceal bleeding is significantly higher than from non-variceal causes, with rates of 15–20% during the first episode. In patients with severe liver disease (Child-Pugh Class C), this mortality can rise to around 30%, while it remains low in compensated cirrhosis patients (Child-Pugh Class A). Key predictors of bleeding include the size of varices, presence of red wale marks, and the Child-Pugh classification. [4]

UGIB is characterized by symptoms such as hematemesis and melena, indicating bleeding from a source proximal to the Treitz ligament [5]. Hematemesis may range from significant hemorrhage to minor bleeding lasting several days, often accompanied by hemodynamic changes. Bright red blood suggests recent hemorrhage, while "coffee ground" material indicates the influence of stomach acid on blood. Melena, characterized by black, tarry stools, results from the impact of the gastrointestinal tract and bacteria on the blood. Hematochezia, or bright red blood in the stool, typically points to lower gastrointestinal bleeding but can also occur with rapid, large UGIB [6].

Risk factors associated with increased mortality, recurrent bleeding, and the need for endoscopic hemostasis or surgical intervention include age over 60, comorbidities, active bleeding (e.g., observed hematemesis or fresh blood per rectum), hypotension, and the transfusion of six or more units of red blood cells [7].

Approximately 80% of upper gastrointestinal bleeding episodes are self-limited and only require supportive therapy. The primary prognostic factors are the underlying cause of bleeding and the presence of comorbidities. Various scoring systems have been developed to assess the risk of rebleeding and mortality associated with upper gastrointestinal bleeding. [8]

Notably, there is limited data on the clinicoetiological profile of gastrointestinal bleeding specific to the Indore region of Madhya Pradesh, prompting this investigation to better understand the clinical and epidemiological profile of adult patients with gastrointestinal bleeding presenting to emergency services.

The study aimed to investigate the etiological profile of patients presenting with upper gastrointestinal bleeding (UGIB). Specifically, the objectives include analyzing the clinical and endoscopic profiles of these patients, identifying the underlying causes of UGIB, and assessing the outcomes of various interventions implemented for its management. Through this comprehensive approach, the study seeks to enhance understanding of UGIB and improve patient care strategies.

After approval from institutional ethical committee, the present observational study was conducted in the Department of Medicine at SAIMS & PG Institute, Indore and 100 adult patients aged more than18 years of age attending OPD or emergency department with upper GI Bleeding (UGIB)(hematemesis, melena, or both) during the study duration and satisfying the inclusion criteria were enrolled. Written informed consent was obtained from all patients after explaining the study protocol.

Inclusion Criteria

• Age >18 years
• Patient with upper GI bleed
• Individual willing to give consent for participating in study

Exclusion Criteria

• Patient less than 18 years of age
• Individuals not willing to give consent for participating in study
• Patients suspected of occult bleeding because of anemia, iron-deficiencyanemia and/or positive hemoccult test with no diagnosis on endoscopy.

Methodology

A pre-designed proforma was utilized to conduct patient interviews and a comprehensive history was taken from all patients, including demographic details such such as age, sex, religion, address, occupation, education, and socioeconomic status using the modified Kuppuswamy classification and presenting complaints, and a thorough account of the presenting illness. Relevant information regarding comorbidities, addiction history (including recent alcohol consumption or chronic use), and medications was also gathered. A detailed physical and systemic examination was conducted, with findings meticulously documented.

Ryle's tube aspiration was performed to check for blood, and a per rectal examination was conducted on all patients to assess for melena. Comprehensive investigations were carried out, including complete blood count, prothrombin time, international normalized ratio, liver function tests (bilirubin, alkaline phosphatase, transaminases, serum albumin, total protein), creatinine, sodium, lipid profile, hemoglobin A1c, hepatitis B surface antigen, anti-hepatitis C virus, stool for occult blood, and abdominal ultrasound or CT scan. The shock index (heart rate/systolic blood pressure, HR/SBP) was calculated for each patient to assess hemodynamic stability.

Upper gastrointestinal endoscopy was performed on all patients suspected or confirmed to have UGIB. For those experiencing severe bleeding, endoscopy was conducted emergently, even during nighttime hours, while patients with minor bleeding underwent the procedure during the day.

Blood transfusions are provided to severely anemic or hemodynamically unstable patients, targeting hemoglobin levels of 7–9 g/dL for variceal bleeds and 9–11 g/dL for non-variceal bleeds. Platelet and fresh frozen plasma transfusions address clotting abnormalities. For ulcer bleeds, IV pantoprazole is given as an 80 mg bolus followed by an 8 mg/hour infusion for 48–72 hours, while variceal bleeding patients receive octreotide starting with a 100 mg bolus and a 50 mg/hour infusion for 72 hours.

Interventions such as variceal band ligation, glue application, adrenaline injection, and sclerotherapy were conducted based on findings. Colonoscopy was done within 24 hours, with preparation involving magnesium sulfate, sodium sulfate, and potassium sulfate; some patients received a split prep. For hemodynamically unstable patients and those with severe comorbidities, colonoscopy was performed within 12 hours. Biopsies were taken when necessary and sent for histopathological examination. In cases of suspected non-alcoholic steatohepatitis (NASH), liver biopsy was recommended but declined by patients, leading to a diagnosis based on clinical criteria.

Statistical Analysis

Data were collected using a preformed structured questionnaire, ensuring fulfilment of inclusion and exclusion criteria. At the study's conclusion, the relevant data were compiled into a master table and organized using a scientific calculator and standard statistical formulas. Statistical analyses were performed using unpaired Student’s t-test, chi-square test, and Z-test, with a p-value of >0.05 considered significant. Appropriate statistical methods were applied to analyze the data, and graphs and tables were created to support the conclusions in the thesis. 

Baseline characteristics of the study population: Majority of study participants (40%) were in the age group of 46–60 years, followed by those aged 31–45 years (34%) and 18–30 years (14%). The mean age of participants was 45.78 ± 13.87 years. Males comprised a significant majority at 72%, while females represented 28%. Most participants (65%) were from rural areas, with 35% from urban regions. Socioeconomically, 34% of participants belonged to the lower middle class, and 30% were classified as lower class. A notable 46% of study subjects were illiterate, followed by 22% with primary education and 22% who were graduates. 12.04% of patients were aged more than 60 years.

Among the study participants, 71 (71%) were having healthy weight BMI (18.5-24.9), 23 (23%) were over-weight (BMI: 25-29.9), 5 (5%) were obese and only one patient was under-weight.The most common co-morbidity was chronic liver disease (28%), followed by Previous history of UGIB (14%), hypertension (14%), and diabetes mellitus (13%). Regarding risk factors, smoking was present in 43%, alcohol consumption in 41%, and NSAID intake in 15%. (Table 1)

Table 1. Profile of socio-demographic parameters of patients with UGIB

Clinical profile of patients:The most frequent presenting complaint in this study was hematemesis (68%) and melena (54%). 29 (29%) patients complained of both hematemesis and melena. The mean shock index was 0.91±0.28. 27 (27%) patients had shock index>1,as shown in Table 2

Table 2. Clinical profile of patients with UGIB

Biochemical and hematological profile of patients: Majority of patients presented with anemia and hyperbilirubinemia in the study. The mean hemoglobin was 8.60 ± 2.1 g/dl, and the mean total bilirubin was 2.73 ± 3.5 mg/dl. 42 (42%) patients had coagulopathy. The mean prothrombin time was 21.01 ±15.95 s, and the mean INR was 1.60 ± 0.68 s. The mean lactate level was 2.71 ±2.53 mmol/l, and the anion gap was 13.31 ±5.12. Biochemical and hematological profile of patients with suspected UGIB are shown in Table 3.

Table 3 Biochemical and hematological profile of patients with UGIB

Upper GI endoscopy/colonoscopy findings: Eight patients, including three with hemorrhoids, two with ulcerative colitis, and three with no obvious source of bleeding, underwent simultaneous colonoscopy after upper GI endoscopy revealed no bleeding source. The most common finding was esophageal varices, present in 51% of cases, followed by gastric ulcers (12%), duodenal ulcers (6%), esophageal ulcers (6%), esophagitis (5%), and gastric carcinoma (2%). This indicates that portal hypertension was identified in over 50% of UGIB cases in our study, as detailed in Table 4.

Table 4 Upper GI endoscopy/colonoscopy findings

Treatment profile and outcome of patients with suspected UGIB:In our study majority of patients (75%) received intravenous fluids (crystalloids), 27 (27%) patients received packed red blood cells, 9 (9%) patients received fresh frozen plasma, whereas only 2 (2%) patients received random donor platelets. Endoscopic variceal ligation was done in 33(33%) patients to control active bleeding. 6 (6%) patients were intubated in emergency department because of poor Glasgow Coma Score (GCS) (<8)

Out of all 100 patients presenting with UGIB, 65 (65%) patients got admitted. 17 (26.2%) patients were admitted to Intensive Care Unit (ICU) out of total admitted. Among 14 (14%) patients who succumbed to death, 3 (18.8%) expired in the emergency department, 4 (25%) deaths occurred within 24 h, and 9 (56.3%) within seven days after admission. Among patients admitted to ICU, 12 (75%) succumbed to death, one (1%) patient left against medical advice, as shown in Table 5.

The mean duration of stay in the emergency department was 12.43 ± 11.68 hours, while the mean hospital stay for patients with upper gastrointestinal bleeding (UGIB) was 6.27 ± 5.01 days.

Table 5. Treatment profile and outcome of patients with UGIB

Cause of mortality in patients with UGIB in Hospital:Septic shock (9;56.3%) was the most common cause of mortality. Septic shock is diagnosed as per ‘Sepsis 3’ definition i.e. ‘any patient who fulfil the criteria for sepsis who, despite adequate fluid resuscitation, require vasopressors to maintain a mean arterial pressure (MAP) more than or equal to 65mmHg and have a lactate more than 2 mmol/L’. It is followed by metabolic acidosis (2;12.5%), hypovolemic shock (2;9.5%), and acute respiratory distress syndrome (2;9.5%), as shown in Table 6.

Table 6. Cause of mortality in patients with UGIB in Hospital

Association between clinical parameters with mortality: Table 8 demonstrates a significant association between mortality and various clinical variables, including high respiratory rate, low SpO2, elevated pulse rate, low systolic and diastolic blood pressure, reduced Glasgow Coma Scale (GCS) scores, and high shock index. Additionally, hematological and biochemical parameters such as low hemoglobin, low hematocrit, low platelet count, high total leukocyte count, elevated lactate levels, and increased blood urea and serum creatinine levels were also significantly linked to mortality.

Table 7. Association between clinical parameters with mortality

Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening medical emergency, often presenting with either frank hematemesis or melena. [9] Patients may initially seek care from their primary family physician. The etiology of UGIB can be subdivided into variceal and non-variceal bleeding. [7] The most common cause of UGIB is gastric ulcer, followed by variceal bleeding in patients with alcoholic liver disease. The approximate incidence of UGIB is 100–200 cases per 100,000 population, with around 65–80% of all bleeding incidents occurring in the upper intestine. [10]

Demographic parameters:In our study, males predominated, with a mean age of presentation of 45.78 ± 13.87 years. A cross-sectional study by Surendran M et al. at a tertiary care hospital in southern India reported that males (107; 77.5%) outnumbered females (31; 22.5%) with an average age of 53.5 ± 13.17 years. [11] Similar findings were noted by Shenoy V et al. [12]. These studies indicate that UGIB is more prevalent in men than in women. In India, the higher prevalence of alcohol use disorder among males is a significant contributor to variceal bleeding in this population [13].

Co-morbidities: In our analysis, chronic liver disease was the most prevalent comorbidity, affecting 28 patients (28%), followed by previous history of UGIB (14%), hypertension (14%), and diabetes mellitus (13%). A study by Mahajan et al. found a significant association between comorbidities such as diabetes mellitus, coronary artery disease, and mortality [14]. Similarly, Bhattarai et al. reported that 45.5% of patients with UGIB had chronic liver disease, 3.7% had chronic hepatitis B, and 1.5% had hepatitis C, aligning with our findings [15]. Previous research indicates that chronic liver disease is more commonly observed in patients with variceal bleeding, while comorbidities like cardiac disease, cerebrovascular accidents, and malignancies are more prevalent in those with non-variceal bleeding [16]. Therefore, screening for comorbidities is crucial in UGIB patients, as these conditions significantly increase the risk of mortality.

Clinical features: In our study, hematemesis was the most prevalent presenting symptom among UGIB patients, followed by melena, abdominal discomfort, abdominal distension, and cases with both hematemesis and melena. Minakari M et al. reported that hematemesis was the most common presentation, occurring in 63.5% of cases [17]. Similar findings were observed by Rajan et al. [18] and Shah H et al. [19]. As a tertiary care and referral center, our hospital serves a large population from Uttarakhand and neighboring states, many of whom come from rural backgrounds. Often, patients may overlook the initial signs and symptoms of melena and seek medical attention only when experiencing significant hematemesis.

Laboratory parameters: Studies by Bhattarai et al. [15] found that anemia was prevalent among the majority of patients with UGIB, consistent with our findings. Similar results were noted by Sharma V et al. [20]. Bressler B et al. [21] highlighted that the formation of esophageal varices is associated with thrombocytopenia (20 μmol/l), recommending that patients with no history of UGIB but with these laboratory values should be screened for varices. Anemia in UGIB patients often results from ongoing blood loss, and those with chronic liver disease may also experience megaloblastic anemia and pancytopenia due to hypersplenism. Additionally, elevated urea and creatinine levels can occur because blood is metabolized into protein, which is then converted to blood urea nitrogen in the liver. This increase may result from dehydration and hypovolemia, with acute UGIB contributing to elevated blood urea nitrogen and creatinine ratios, alongside reduced renal perfusion.

Upper GI endoscopy findings: Earlier research supports our findings, with Surendran M et al. [11] noting that esophageal varices (51.4%) were the most common finding, followed by gastritis (15.2%). Paudal MS et al. [22] reported that duodenal ulcers were present in 29% of cases, while varices appeared in 23%. In contrast, Kashyap R et al. [23] found peptic ulcers in 61% of patients. This discrepancy may be due to a higher prevalence of alcoholic liver disease in our region, influencing the observed etiology of UGIB.

Interventions: Various treatment modalities exist for acute UGIB, including injections of epinephrine (1:10,000 dilution), sclerosants like 100% ethanol, thermal contact devices such as bipolar electrocoagulation probes or heater probes, and clips for bleeding ulcers. Shenoy V et al. [12] reported that PRBC transfusion was performed in 46.7% of cases, while our study noted a rate of 26.6% (37 cases). Additionally, JP Hreinson et al. [24] found that 60% of patients with UGIB required blood transfusion. In O’Donnell’s study, among 100 patients who developed gastrointestinal hemorrhage during hospitalization after an acute ischemic stroke, 36 (0.5%) required blood transfusion. [25]

Outcomes: In our study, 100 patients presented with UGIB, of whom 65 (65%) required hospitalization. This aligns with findings by J P Hreinsson et al., who reported that 71% of 156 patients with UGIB were hospitalized [24]. Most patients with acute UGIB need hospitalization for hemodynamic stabilization and immediate intervention. Rajan et al. [18] noted that 34.8% of patients with UGIB died within 24 hours of presentation, while Moledina S et al. [26] found that 24.6% succumbed within the same timeframe, and 49.1% within 72 hours. Our study indicated a higher mortality rate, underscoring the critical need for early intervention to improve patient outcomes. The mean emergency department stay for our patients was 12.43±11.78 hours, with a mean hospital stay of 6.21±5.01 days, compared to 5.63 days reported by Mungan Z et al. [27]. After stabilization, patients were placed on intravenous octreotide infusion or terlipressin injections for 48 to 72 hours per guidelines.

UGIB is a prevalent emergency condition frequently encountered by family medicine physicians and emergency physicians. The etiology can vary, including gastric ulcers, chronic liver disease, and coagulopathies. Immediate stabilization of these patients is crucial, followed by early upper GI endoscopy to facilitate appropriate interventions. Collaborative management by both primary care and emergency medicine physicians is essential for optimal patient outcomes.

One potential drawback of our study is that it was conducted at a single center and within a specific time frame, which may limit the generalizability of the findings. Additionally, the sample size was determined through convenient sampling, introducing a limitation in the representation of the broader population.

In conclusion, our study highlights the critical role of early intervention in managing upper gastrointestinal bleeding (UGIB), particularly in patients with portal hypertension. Hematemesis emerged as the predominant symptom, with a significant proportion of patients requiring blood transfusions. The prevalence of comorbidities such as alcohol use, NSAID abuse, and chronic liver disease underscores the need for comprehensive patient assessment.

Early endoscopy proves to be a vital strategy in reducing both morbidity and mortality associated with UGIB. By enhancing awareness of the underlying causes, associated risk factors, and key mortality predictors, healthcare providers can improve outcomes through timely intervention and patient education. Proactive management is essential to prevent delays that could compromise patient health, ultimately leading to more effective control of acute UGIB.

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