Upper gastrointestinal bleeding (UGIB) is a common problem in emergency and inpatient departments. The mortality rate ranges from 0.8% to 14% [1-3]. Higher mortality is associated with increasing age, presence of severe comorbidity, and rebleeding [3].
The etiology of UGIB is classified into two major groups, nonvariceal bleeding and variceal bleeding. Peptic ulcers and gastritis are mostly found in the nonvariceal group, whereas, variceal bleeding is associated with cirrhosis or liver disease. The proportions found vary between studies. In some studies, the most frequent causes are peptic ulcer and gastric erosion [4, 5].
Esophago–gastro–duodenoscopy is used globally to assess gastrointestinal bleeding. It can be performed under local anesthesia and in emergency settings. It allows not only direct visualization of the upper gastrointestinal tract, but intervention to stop bleeding and tissue biopsy. Endoscopy findings can predict the likelihood of rebleeding [11], and provide information for further management planning.
It has been 20 years or more since the epidemiology of UGIB in Thailand, and the prevalence of
After approval from Institutional Review Board of Faculty of Medicine Chulalongkorn University, Bangkok, Thailand (IRB approval number is 359/57), data from patients who attended the endoscopy unit of the Department of Internal Medicine, King Chulalongkorn Memorial Hospital, from June 2007 to January 2013 were retrieved from the MasterScope database. King Chulalongkorn Memorial Hospital is a tertiary care university medical center, located in central Bangkok. All information including sex, age, indications, procedures, endoscopic finding, treatment, Campylobacter-like organism (CLO) test results and whether biopsy was performed was recorded in a computer-based system.
The keywords “upper gastrointestinal bleeding” and “iron deficiency” in indication were used to select subjects from the database. Data from patients less than 10 years old, those with successive endoscopic studies to follow up, incomplete study, uncertain diagnosis, and normal findings were excluded. Data from patients with iron deficiency where the findings did not explain iron deficiency, or who needed lower gastro–enteroscopy, were excluded. Furthermore, data from patients with diagnoses that were outside the upper gastrointestinal tract, such as jejunal ulcer and gastrojejunal ulcer were also excluded from the study. The CLO test from tissue biopsy under endoscopy was used to diagnose
The etiology of upper gastrointestinal bleeding was categorized into 10 groups. Patients were categorized into the groups, based on endoscopic findings and diagnoses. Statistical data were calculated using SPSS Statistics version 17.0 (SPSS, Chicago, IL, USA). Chi-square and Student
Etiologies were classified into 10 groups: gastric ulcer, duodenal ulcer, concurrent gastroduodenal ulcer, nonulcer-mucosal lesion, esophageal-related cause, cirrhosis, concurrent peptic ulcer disease with cirrhosis, malignancy, vascular lesion, and miscellaneous
The 4,454 endoscopic findings, association with “Total” means numbers of patients who had the lesion and were on Campylobacter-like organism (CLO) test. “Case” means patients who had the lesion and were positive on CLO test. bSignificant difference between Significant difference between the mean age of a lesion and lesion-free on each endoscopic findingMean age ± SD (years) Lesion positive Lesion negative Gastric ulcer 936 (21) 150/589 (25.5) 0.89 0.3 66.52 ± 13.9 62.12 ± 16.5 <0.001 Duodenal ulcer 472 (10.6) 99/277 (35.7) 1.62 <0.001 62.29 ± 17.7 63.46 ± 15.6 0.18 Concurrent gastroduodenal ulcer 293 (6.6) 71/194 (36.6) 1.63 0.001 67.15 ± 13.9 62.95 ± 16.1 <0001 Non-ulcer-mucosal lesion 1,043 (23.4) 147/634 (23.2) 0.73 0.007 63.58 ± 16.1 63.18 ± 15.9 0.50 Esophageal-related cause 910 (20.4) 115/424 (27.1) 1.00 0.94 64.16 ± 17.3 63.00 ± 15.4 0.08 Cirrhosis 399 (9) 1/32 (3.1) 0.08 0.002 54.87 ± 13.5 64.39 ± 15.9 <0.001 Concurrent peptic ulcer disease with cirrhosis 192 (4.3) 9/62 (14.5) 0.45 0.024 58.71 ± 13.4 63.57 ± 16.0 <0.001 Malignancy 103 (2.3) 8/26 (30.8) 1.19 0.66 62.44 ± 14.3 63.33 ± 15.9 0.58 Vascular lesion 69 (1.6) 2/11 (18.2) 0.59 0.51 67.87 ± 13.4 63.21 ± 15.9 0.01 Miscellaneous 37 (0.8) 0/2 (0) 0.00 0.39 62.97 ± 18.9 63.30 ± 15.9 0.90
Patients with mucosal lesions and ulcers were categorized into the ulcer group only. For example, a patient who had gastritis and gastric ulcer, was placed into an ulcer group. Nevertheless, there was 26% of patients who had more than one endoscopic finding. The percentage of each cause was based on numbers of diagnoses because some patients had more than one potential bleeding lesion at endoscopy.
The leading cause of UGIB in this study was peptic ulcer (38.2%). There was 21% of gastric ulcers, 10.6% of duodenal ulcers, and 6.6% of concurrent gastroduodenal ulcers. The second and third leading causes were nonulcer-mucosal lesion (23.4%), and esophageal-related causes (20.4%). Cirrhosis was 9% and concurrent peptic ulcer disease with cirrhosis was 4.3%. Malignancy was 2.3%.Vascular lesion and miscellaneous groups were least prevalent at 1.6% and 0.8% respectively
When lesions or masses suspected of malignancy were identified at endoscopy, each patient’s medical record was reviewed to confirm the diagnosis with tissue-pathology results. Malignancy was diagnosed in 103 of patients (2.3%). There were 12 types of cancer that caused UGIB. These cancers are presented in
Type of malignancy that caused upper gastrointestinal bleeding with proved tissue-pathologyType of cancer Number of patients Gastric cancer (adenocarcinoma) 36 Gastric lymphoma 15 Other cancers metastasis 15 Esophageal cancer (squamous cell carcinoma) 12 Gastrointestinal stromal tumor (GIST) 11 Ampullary cancer (adenocarcinoma) 4 Periampullary cancer 3 Pancreatic cancer 3 Duodenal cancer (adenocarcinoma) 1 Pancreatic endocrine tumor 1 Epiglottic cancer 1 Pyriform sinus cancer 1
There were 37 patients who were classified into a miscellaneous group. They were 22 of post-procedural bleeding (i.e. sphincterotomy, gastrectomy, and balloon dilation), 5 of anastomosis bleeding, 3 of hemobilia, 3 of bleeding from duodenal diverticulum, 2 of Crohn’s disease, 1 of bleeding gastric benign polyp, and 1 of pancreatic pseudo-aneurysm.
The incidence of
Of 3,488 patients, 1,712 subjects (49.1%) had a CLO test during endoscopy. Physicians performing endoscopy decided whether the patient should have a CLO test. This depended on the characteristics of lesions found under endoscopy.
Data revealed that duodenal ulcers and concurrent gastroduodenal ulcers as endoscopic findings were significantly associated with
Patients, who were infected with
The mean age of patients with cirrhosis was 54.87 ± 13.5 years and differed significantly from noncirrhosis patients (64.39 ± 15.9 years). Patients with vascular lesions and concurrent gastroduodenal ulcer had the oldest mean age of 67 years. Malignancy was found mostly in age 62.44 ± 14.3 years and was not significantly different from the mean age of patients in the group without malignancy group
The prevalence of
Age-specific prevalence of Percentage of H. pylori positive or lesion positive comparing within each age groups age-specific groups and NUM = nonulcer-mucosal lesion, GU = gastric ulcer, DU = duodenal ulcerAge group(y) H. pylori positive no. of cases (% NUM no. of cases (%) GU no. of cases (%) DU no. of cases (%) esophageal-related cause no. of cases (%) Cirrhosis no. of cases (%) Malignancy no. of cases (%) Vascularno. of cases (%) <40 63 (43.8) 95 (31.5) 44 (14.6) 58 (19.2) 96 (31.8) 49 (16.2) 8 (2.6) 2 (0.7) 40-59 134 (31.4) 276 (27.5) 212 (21.2) 128 (12.8) 219 (21.9) 209 (20.9) 33 (3.3) 17 (1.7) 60-79 205 (23.7) 512 (31.1) 511 (31.1) 203 (12.3) 416 (25.3) 128 (7.8) 52 (3.2) 38 (2.3) >79 60 (21.7) 160 (29.7) 169 (31.4) 83 (15.4) 179 (26.1) 13 (2.4) 10 (1.9) 12 (2.2)
Some endoscopic findings were significantly different between age groups. Gastric ulcer was significantly more often identified in older patients. By contrast, duodenal ulcer was significantly more frequent than in patients <40 years and >79 years. Cirrhosis was more often found in the younger patients. Malignancy prevalence was around 2% to 3% in every age group. Vascular lesions were more often found in older patients; however, there was no significant difference between age groups. The prevalence of nonulcer-mucosal lesions was not significantly different between age groups
UGIB is a common presentation at hospitals. The male to female patient ratio was 1.4:1 and the mean age of patients was 63.3 years, higher than a decade ago. One study conducted of the Thai population in the 1990s, found that the mean age was 5.3 years younger at 54 years [5]. The ratio of male and female patients was 3.3:1 in the early 1990s [5]. This means that there were more female patients presenting at hospital with UGIB.
In a meta-analysis conducted by Huang et al. [6], peptic ulcer was found to be more common in patients taking NSAIDs, irrespective of
Gastric ulcer was more frequently found than duodenal ulcer in this study. The ratio of gastric ulcer to duodenal ulcer did not change, compared with that found in a study in the Thai population more than a decade earlier [5]. Duodenal ulcer and concurrent gastroduodenal ulcer were associated with
Nonulcer-mucosal lesions (NUM) included less severe mucosal lesions such as gastritis, duodenitis, mucosal erosion, and hemorrhagic gastritis. They were the second leading cause of UGIB in our study. The prevalence of NUM declined during the past decade. A study in the Thai population found a prevalence of 31.6% in the 1990s [5]. The study by Gilbert et al. in the United States in 1981, found a prevalence of 38.7% [4]. In our study, NUM was significantly unrelated to
Esophageal-related causes included GERD, esophageal ulcer, hiatal hernia, Cameron ulcer, Mallory–Weiss syndrome, esophageal candidiasis, and Barrett’s esophagus.
Cirrhosis and concurrent peptic ulcer disease with cirrhosis were found to be negatively associated with
Malignancy was found in 2.3% of all cases. It increased from 1.66% [5] to 2.3% during the past decade or more. The difference in prevalence might be the result of the variety of cancers diagnosed. Saowaros et al. [5] reported only three types of cancer, which were esophageal, stomach, and ampulla cancer. However, in our study, we found 12 types of cancers in patients who presented at our hospital with UGIB. The most common cancer was adenocarcinoma of stomach. Lymphoma and other cancer metastasis were the second most common. The least found cancers were duodenal adenocarcinoma (1 case), pancreatic endocrine tumor, epiglottic cancer, and pyriform sinus cancer. The last two cancers were found in patients with UGIB. Although, some studies show that
Neither vascular lesions nor a miscellaneous group were associated with
The mean age of patients with each diagnosis was different. Most patients were >60 years, except for those with cirrhosis or concurrent peptic ulcer with cirrhosis, who were 54.9 and 58.7 years old respectively. Patients diagnosed with concurrent gastroduodenal ulcer and vascular lesions were oldest at a mean 67 years for both groups, and were significantly older compared with patients without lesions.
Annual incidence of
For each diagnosis, we also found a statistical difference in the number of patients between age-specific groups with gastric ulcer, duodenal ulcer, esophageal-related causes, and cirrhosis. Gastric ulcer was found increasingly with greater age, while, cirrhosis was found to decline with age. Cirrhosis possibly had decreased prevalence with age because cirrhotic patients have shorter life expectancy [19]. Esophageal-caused UGIB prevalence was significantly different in each age group, but this may be not be clinically important. It ranged from 20%– 30% in all age group. Although the prevalence of duodenal ulcer was bimodal, peaking at age <40 and >79 years, this may not be clinically important. Malignancy was found mostly at age 40-79 years. It was less found in age groups at either extreme, <40 years and >79 years. This may be because it is less likely that malignancy occurs in younger patients and fewer patients with cancer will live through the age of 80 years.
The most common cause of UGIB was peptic ulcer disease. Nonulcer-mucosal lesion and esophageal-related causes are the second and third most common etiology.