Upper gastrointestinal bleeding: incidence, etiology and outcomes in a population-based setting

Figures & data

Figure 1. A flow chart showing patients who were included in the study and the patient groups that were excluded. UGE = upper gastrointestinal gastroscopy; AUGIB = acute upper gastrointestinal bleeding.

Table I. The crude annual incidence of AUGIB is illustrated as well as age standardized incidence rates for certain age groups.

Incidence (n = 132)	Per 100,000
AUGIB incidence rate	87
Age standardized incidence rate
18–24	30
25–39	15
40–59	48
60–79	213
80–105	570

Abbreviation: AUGIB = acute upper gastrointestinal bleeding.

Individuals who were non-residents of the greater metropolitan area were all excluded. The oldest person in the greater metropolitan area during the study period was 105 years old.

Table II. The diagnoses found in the total study cohort.

Diagnosis	n (%)
Duodenal ulcer	32 (20.5)
Gastric ulcer	23 (14.7)
Mallory–Weiss tear	19 (12.2)
Esophagitis	15 (9.6)
Other^1	12 (7.7)
Unexplained bleeding	10 (6.4)
Vascular ectasia	8 (5.1)
Gastric and duodenal ulcer	7 (4.5)
Mucosal erosive disease	7 (4.5)
Esophageal varices	6 (3.8)
Ulcer on anastomosis	5 (3.2)
Gastric cancer	4 (2.6)
Esophageal ulcer	4 (2.6)
GIST	4 (2.6)
Total	156

Abbreviation: GIST = gastrointestinal stroma tumor.

¹Among the diagnoses in the group named “Other” were: idiopathic thrombocytopenic purpura, portal hypertensive gastropathy, bleeding from the biliary tract caused by cancer invasion, bleeding after a biopsy, bleeding after a papillotomy, herpes esophagitis, bleeding after a partial gastroduodenostomy, Dieulafoy’s lesion and a stoma ulcer. In three patients the lesions were unspecific.

Table III. The use of drugs considered a priori to be potentially related to increased risk of GI bleeding.

Drug	% AUGIB (n = 156)	% Control group (n = 312)	p-value
NSAIDs	20% (31)	8% (24)	0.0002
NSAIDs + LDA	8% (13)	1% (4)	0.0003
Warfarin	15% (23)	7% (21)	0.0069
LDA	40% (62)	30% (93)	0.0371
LDA + SSRIs	8% (12)	3% (9)	0.0302
Warfarin + SSRIs	3% (4)	0% (1)	0.0444
PPIs	40% (62)	49% (152)	NS
NSAIDs + PPIs	8% (13)	4% (14)	NS
SSRI drugs	16% (25)	12% (37)	NS
Platelet inhibitors^1	7% (11)	5% (16)	NS
Bisphosphonate drugs	4% (7)	3% (10)	NS
LMWH/Heparin	5% (8)	4% (11)	NS
Corticosteroids	3% (5)	3% (8)	NS
LDA + warfarin	4% (6)	2% (7)	NS
NSAIDs + warfarin	3% (4)	1% (3)	NS
NSAIDs + SSRI	3% (5)	1% (3)	NS
Platelet inhibitors + SSRIs	2% (3)	1% (2)	NS

Abbreviations: LDA = low-dose aspirin; LMWH = low-molecular-weight heparin; NSAIDs = non-steroidal anti-inflammatory drugs; PPIs = proton pump inhibitors; SSRIs = selective serotonin receptor antagonists; NS = Not significant.

¹Platelet inhibitors included were: clopidogrel, prasugrel, dipyridamole and ticlopidine.

Table IV. Comparison between patients with clinically significant bleeding and patients with non-clinically significant bleeding.

Variable	Clinically significant (n = 105)	Not clinically significant (n = 51)	p-value
Age	67 (±17)	62 (±22)	NS
Gender	48% female	31% female	NS
Hb	82 (±13.2)	120 (±21.6)	0.0001
Hematocrit	0.25 (±0.037)	0.35 (±0.058)	0.0001
Platelets	255 (±148)	227 (±104)	NS
Creatinine	106 (±125)	94 (±60)	NS
PT	15.3 (±2.2)	13.8 (±2)	NS
INR	2.5 (1.4)	1.4 (0.4)	NS
Duodenal ulcer	25 (24%)	7 (14%)	NS
Gastric ulcer	20 (19%)	3 (6%)	0.031
Mallory–Weiss tear	8 (8%)	11 (22 %)	NS
Esophagitis	6 (6%)	9 (18%)	NS
Unexplained bleeding	2 (2%)	8 (16%)	NS
Vascular ectasia	2 (2%)	6 (12%)	NS
Gastric and duodenal ulcer	7 (7%)	0 (0)	NS
Mucosal erosive disease	4 (4%)	3 (6%)	NS
Esophagal varices	6 (6%)	0 (0)	NS
Ulcer on anastomosis	5 (5%)	0 (0)	NS
Gastric cancer	4 (4%)	0 (0)	NS
GIST	4 (4%)	0 (0)	NS
Esophageal ulcer	1 (1%)	3 (6%)	NS
NSAIDs	28 (26.7%)	3 (5.9%)	0.0023
LDA	45 (42.9%)	17 (33.3%)	NS
Warfarin	14 (13.3%)	9 (17.6%)	NS
SSRI drugs	17 (16.2%)	8 (15.7%)	NS
Anti-platelet drugs	4 (3.8%)	7 (13.7%)	0.0404
Bisphosphonates	6 (5.7%)	1 (2%)	NS
NSAIDs + LDA	13 (12.4%)	0 (0%)	0.0053
LDA + SSRIs	9 (8.6%)	3 (5.9%)	NS
LDA + warfarin	4 (3.8%)	2 (3.9%)	NS
NSAIDs + SSRIs	3 (2.9%)	2 (3.9%)	NS

Abbreviations: GIST = gastrointestinal stroma tumor; Hb = hemoglobin; INR = International Normalized Ratio; LDA = low-dose aspirin; NSAIDs = non-steroidal anti-inflammatory drugs; PT = prothrombin time; SD = standard deviation; SSRIs = selective serotonin receptor antagonists.

Data presented as mean ± SD or as count and percentage.

Table V. General data on patients undergoing acute surgery or had an AUGIB-related death.

	M77	M57	M31	M58
Death	Yes	Yes	No	No
Surgery	No	Yes	Yes	Yes
Hb at presentation	79	88	79	81
Blood transfusions	8	147	0	17
Drugs	LDA + warfarin	Warfarin + PPIs	No drug intake	NSAIDs + LDA + PPIs
Co-morbidities	End-stage COPD	Ischemic heart disease + coagulopathy	Liver cirrhosis + end-stage renal failure	No co-morbidities

Abbreviations: AUGIB = acute upper gastrointestinal bleeding; COPD = chronic obstructive pulmonary disease; Hb = hemoglobin; LDA = low-dose aspirin; NSAIDs = non-steroidal anti-inflammatory drugs; PPIs = proton pump inhibitors.