Factors predicting mortality of elderly patients with acute upper gastrointestinal bleeding

The study was approved by the institutional review board of each hospital involved. The hospitals included King Chulalongkorn Memorial Hospital (approval No. 480/51), Maharat Nakhonratchasima Hospital (approval No. 0027.124/443), Sawanpracharak Hospital (approval No.1/2552), Surin Hospital (approval No. 0027.102/12475), Maharaj Nakhonsithammarat Hospital (approval No. 002/2555), HRH Princess Maha Chakri Sirindhorn Medical Center (approval number 49/2552 SWUEC 5-5/2552), Chonburi Hospital (approval No. 23/2553), Bangkok Metropolitan Administration General Hospital (approval No. W68), Bangkok Hospital (approval 23/12/2552), Rajavithi Hospital (approval No. 52116), and Thammasat University Hospital (approval No. MTU-E-1-78/ 52).Written informed consent was obtained from each patient or their nearest relative before enrollment at each center.

We prospectively enrolled 981 patients with UGIB from 11 hospitals in Thailand during the study period from January 2010 to September 2011. The mean age ± SD of the patients was 59.4 ± 14.9 years (range 17 - 94 years) and they included 661 men (67%). Of 981 patients, 499 (50.9%) were elderly with UGIB. Management of UGIB was based on the Consensus for Clinical Practice Guidelines for the management of UGIB from the Thai Association for Gastrointestinal Endoscopy. All patients presenting to the emergency or outpatient departments with acute UGIB were clinically assessed initially and hemodynamically stabilized. Gastroenterologists were informed. Every patient was admitted to hospital and an esophagogastroduodenoscopy (EGD) was performed according to a standardized examination protocol. If endoscopy was not available, the patient was considered for referral. Clinical management, including medication, fluid resuscitation, and the timing of endoscopy and endoscopic therapy was decided by each individual gastroenterologist. Packed erythrocyte (PRC) transfusion was considered when hemoglobin was less than 9 g/dL. If endoscopic treatment failed, the rescue therapy was surgery or embolization. The Rockall score is the best-known of all tools for risk stratification of patients with acute UGIB. It was formulated by medical institutions in the England in 1996 and its primary negative outcome is mortality [3]. The Rockall score consists of 5 variables and is the most widely used and validated tool to predict outcome in clinical practice [6]. In the present study, we used complete Rockall scores to predict outcome in elderly patients with acute UGIB and search for other predictive factors.

The main findings of the present study were factors predictive for mortality of elderly patients with acute UGIB. The elderly are a special population who are prone to have more complications from any illness because of their physiological instability, and from comorbidities and medications. In this study, we focused on elderly patients with acute UGIB, in terms of mortality and factors predictive of mortality. The cause of UGIB was peptic ulcer bleeding in 84.8% of patients, which is consistent with previous studies [13-16]. The cause of peptic ulcer bleeding might be from ulcerogenic medications (including aspirin, clopidogrel, NSAIDs, and warfarin). Rebleeding in this study was found to be around 1%; very low compared with a previous study [13]. Mortality was found to be 9% as consistent with previous studies [12-13], but lower than in some studies that found high mortality in the elderly ranging from 12% to 25% [17-19]. An extremely elderly population had mortality rates higher than a moderately elderly group (13.6% and 8.1% respectively), with no significant difference between them (P = 0.1). The low mortality found in the present study may be explained by new devices used to stop bleeding, and the skill of the physicians as exemplified by the low rate of surgical rescue and invasive radiological interventions (1.6%) reported. The leading causes of death were sepsis and multiorgan failure.

In the present study, there were no differences in mortality among elderly patients with UGIB and low, moderate, or high Rockall scores, which differs from earlier research that found the Rockall score to be clinically useful and accurate in predicting rebleeding, rescue surgery, and mortality in elderly patients [12], and patients in all age groups [20-23]. However, if we look at individual factors in the Rockall score, the results are different in univariate analysis. The present study found pulse rate >100 beats per min, comorbidities with CAD or chronic kidney disease, and endoscopic findings of gastric varices were significantly associated with mortality.

Factors predictive of mortality are clinically important in the management of disease because patients with such factors should be evaluated first and repeatedly. We found that independent factors predictive of mortality were a pulse rate of >100 beats per min, red blood in the nasogastric tube, comorbidity with coronary artery disease, and creatinine more than 1.5 mg/dL. This information is important in clinical practice because these factors in patients should alert doctors to perform prompt resuscitation, urgent endoscopic diagnosis, and treatment to reduce mortality. Previous studies found early predictors of adverse prognosis in acute UGIB in the elderly, were shock, severe comorbidities, red blood emesis, variceal bleeding, gastric ulcer larger than 2 cm, and units of blood transfused [11, 24-28]. Rapid clinical triage decisions in emergency acute UGIB is crucial. The most common cause of acute UGIB was peptic ulcer bleeding (gastric or duodenal ulcer), which is not surprising considering Helicobacter pylori infection is found in 48.2% of the Thai population [29]. Explanations for the cause of peptic ulcer bleeding are common concomitant use of aspirin, clopidogrel for prevention of atherosclerosis, and excessive use of NSAIDs for musculoskeletal pain.

The strength of this study is the use of sample data from multiple centers in four regions of Thailand, which reflect authentic life clinical situations and practices. There are some limitations in this study. First, the decision regarding the endoscopic therapy and blood transfusion is subjective, and there may be variability between gastroenterologists among the 11 centers. Second, emergency endoscopies were not available in several of the study centers. Third, patients with UGIB managed as outpatients were not enrolled in this study.

The 30 day mortality in elderly patients with UGIB was found to be 9%. The most common cause was peptic ulcer bleeding. Factors predictive of mortality were found to be a pulse rate of more than 100 beats per min on first visit, red blood cells in nasogastric aspiration, and comorbidities, such as having CAD or a creatinine level of more than 1.5 mg/dL. These factors should be taken into consideration when triaging high risk patients for immediate attention, resuscitation, close monitoring, and early treatment.