|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2021 | Volume
: 16
| Issue : 2 | Page : 325-328 |
|
Endoscopic profile of acute upper gastrointestinal bleed in adults: A tertiary care center-based study in South India
Sachin K Dhande1, Anbalagan Pichaimuthu2
1 Department of Medical Gastroenterology, Saveetha Medical College, Chennai, Tamil Nadu, India
2 Department of Surgical Gastroenterology, Saveetha Medical College, Chennai, Tamil Nadu, India
| Date of Submission | 01-Dec-2020 |
| Date of Decision | 30-Jan-2021 |
| Date of Acceptance | 18-Mar-2021 |
| Date of Web Publication | 18-Oct-2021 |
Correspondence Address:
Dr. Anbalagan Pichaimuthu
W 186, 1st Floor, North Main Road, Anna Nagar West Extension, Chennai - 600 101, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdmimsu.jdmimsu_383_20
Background: Acute upper gastrointestinal bleeding (UGIB) is one of the most common causes of medical emergencies and associated with high morbidity and mortality in adults. Although there is decline in peptic ulcer bleed as an etiology of acute UGI bleed due to discovery of proton pump inhibitors, the Emergency Room (ER) visits for UGI bleed are increasing due to other etiologies including variceal bleed and drug-induced gastrointestinal (GI) bleed. This study was designed with the aim to assess the endoscopic profile of UGIB presenting to our tertiary care center in south India. Materials and Methods: This was a prospective analytical study. It was done over a period of 6 months from January 2020 to June 2020. All adult patients presenting with acute hematemesis and/or melena were included in the study. All included patients underwent detailed history, clinical examination, blood tests, and upper GI endoscopy. Results: One hundred and eighty-two patients were included in the study. Out of 182 patients, 76% were males. The most common age group was 51–60 years contributing to 34%. The commonest presentation was hematemesis than that of melena. Out of all patients, 69% of patients were hemodynamically stable and 31% patients were unstable at the time of admission. The causes of bleed included esophageal varices, gastric varix, peptic ulcer, portal hypertensive gastropathy (PHG), Mallory-Weiss tear, gastric cancer, drug-induced gastritis, and esophageal tear. Variceal bleed was the most common cause of UGI bleed comprising 34.16% of cases. Conclusions: From our study, we conclude that the most common cause of upper GI bleed in our part of India is portal hypertension related bleeding which included esophageal varices, gastric varices, and severe PHG. This was in contrary to most of the studies from other part of the country as peptic ulcer is far more common than variceal bleed in other studies.
Keywords: Gastrointestinal bleed, peptic ulcer disease, variceal bleed
How to cite this article:
Dhande SK, Pichaimuthu A. Endoscopic profile of acute upper gastrointestinal bleed in adults: A tertiary care center-based study in South India. J Datta Meghe Inst Med Sci Univ 2021;16:325-8 |
| Introduction | |  |
Upper gastrointestinal bleeding (UGIB) is one of the most common gastrointestinal (GI) medical emergencies and remains a major cause of morbidity and mortality. UGIB refers to GI blood loss whose origin is proximal to the ligament of Treitz. The hospitalization rate for UGIB is almost six fold higher than for lower GI bleeding.[1],[2],[3] UGIB is broadly categorized into variceal and nonvariceal bleeding. This distinction becomes crucial as the management strategies are different for variceal and nonvariceal bleeding.[4] Hematemesis and melena are the most common presenting symptoms. The prevalence of UGIB is 170 cases per 100,000 per year, but its incidence varies from 50 to 150 per year in the USA and 100–107 per 100,000 per year in the UK.[5] The common causes of UGIB include duodenal ulcer, gastric ulcer, erosive mucosal disease, varices due to portal hypertension and Mallory–Weiss tear (MWT). Less common causes include esophagitis, neoplasms, and angiodysplasia. The most common cause of UGIB is peptic ulcer in western countries.[6] In 1983, a study from AIIMS, Anand et al. reported variceal bleed (45%) as the most common cause of UGI bleed[1] in India, but a few studies from different centers in India reported duodenal ulcer as the most common cause of upper GI bleeding. Hence, we have conflicting data on UGIB from India. At present, there is a paucity of data on clinical and endoscopic profile of patients of UGIB and their risk factors for mortality from India and particularly from this region. Therefore, this study was planned with an aim to identify clinical and endoscopic profile of patients with UGIB coming to our hospital.
| Materials and Methods | | |
This was a prospective analytical study. It was done over a period of 6 months from January 2020 to June 2020. All adult patients presenting with acute hematemesis and/or melena were included in the study. All included patients underwent detailed history, clinical examination, blood tests, and upper GI endoscopy (UGIE). The analysis of all the observation was done.
Inclusion criteria
- All adult patients presenting to hospital with acute hematemesis and/or melena.
Exclusion criteria
- Patients who were not willing to participate in study
- Patients who are not fit for UGI endoscopy or unwilling to undergo UGI endoscopy
- Pediatric patients (age <18 years of age).
All consecutive patients of UGIB willing to participate were subjected to detailed history and clinical examination. The basic information was recorded which included age, sex, and address. History regarding alcohol intake, nonsteroidal anti-inflammatory drugs (NSAIDs) use, previous UGI bleed, and anti-coagulants were noted. General physical examination essentially included: pulse, blood Pressure, and respiratory rate. Clinical examination included inspection, palpation, percussion, and auscultation of the abdomen. Biochemical investigation included: Complete blood count, blood sugar, and liver function.
UGIE was performed within 12 h of admission for suspected variceal bleed and within 24 h of admission for suspected nonvariceal bleed. This was according to the World Gastroenterology Organization guidelines. UGIE was performed only after hemodynamic stabilization of the patient. It was performed using Olympus CV 150 UGIE.
| Results | | |
During the study, a total of 182 patients were included in the study. Of 182 patients 138 patients (75.8%) were male and 44 patients (24.2%) were female. We grouped our patients by age into six groups as follows: age 18–30 years–20 (11%) patients, age 31–40 years-27 (14.8%) patients, age 41–50 years-35 (19.2%) patients, age 51–60 years-62(34%) patients, age 61–70 years 26 (14.2%) patients, and age 71 years and above–12 (6.6%) patients. History of chronic alcohol intake was present in 100 patients (54.94%) and history of prolonged NSAID intake was present in 40 (22%). Thirty-one patients (17%) had a history of similar complaints, of which 18 had a history of variceal ligation/sclerotherapy/glue injection for varix, four patients had previous history of bleeding from peptic ulcer.
Abdominal examination revealed ascites in 43 (23.6%) cases, epigastric tenderness in 26 (14.2%) cases, hepatomegaly in 20 (11%) cases, splenomegaly in 16 (8.8%) cases, palpable lump in 7 (3.8%) cases and normal findings in 110(60.4%) cases. Ultrasonography (USG) abdomen was suggestive of chronic liver disease with portal hypertension in 80 patients (44%), fatty liver in 20 (11%) cases, ascites with normal liver in 6 cases (3.29%).
On UGIE: [Figure 1] Varices were seen in 64 cases (35.16%) out of which 52 had esophageal or Gastroesophageal Varices (GOV) and 12 had isolated gastric varices, peptic ulcers were seen in 31 cases (17%), gastric ulcer in 20 cases (11%), carcinoma stomach in 17 patients (9.34%), severe esophagitis with or without tear in 15 patients (8.24%), severe erosive gastritis in 12 cases (7.69%), MWT in 8 cases (4.39%), normal endoscopy 8 cases (4.39%), severe portal hypertensive gastropathy (PHG) without varices in 5 cases (2.74%). So of all cases portal hypertension related bleeding consisted of 38% cases including esophageal varices, gastric varices, and severe PHG [Figure 2].
| Discussion | | |
The age of study population varied from 18 years to 90 years with the mean age of 42.6 ± 10.63 years. The maximum number of patients was in the age group of 51–60 years with 62(34%) patients. This showed some resemblance with study done by Kashyap et al.[7] Out of 182 patients, 138 (75.8%) were male and 44 (24.2%) were female. Presenting symptom was hematemesis alone in 42% cases, hematemesis with melena in 30% cases and melena alone in 28% cases. These findings were in contrary to previous Indian studies where melena was more predominant presentation than that of hematemesis.[8],[9],[10] The patient with both hematemesis with melena were more hemodynamically and clinically unstable than that of either hematemesis or melena alone. The patients with melena alone were more clinically stable than that of hematemesis alone or combination of hematemesis and melena. On the assessment of hemodynamic status, we found out that only 31% patients were hemodynamically unstable. They required fluid resuscitation or blood transfusion or vasopressors or combination of those, prior to UGIE. About 69% cases were hemodynamically stable at the time of presentation.
Abdominal examination was normal in 110 patients (60.4%), hepatomegaly in 20 cases (11%), ascites in 43 (23.6%) patients, splenomegaly in 16 cases (8.8%), epigastric tenderness was present in 26 (14.2%), and lump was palpable in 7 (3.8%) patients. USG abdomen was suggestive of chronic liver disease with portal hypertension in 80 patients (44%), fatty liver in 20 (11%) cases, and ascites with normal liver in 6 cases (3.29%).
On laboratories, more than 38% cases had severe anemia (mean Hgb 7+ or –1.6 g%) at the time of presentation. Most of these patients had prior history of UGI bleed due to varices of peptic ulcer disease (PUD). USG abdomen was suggestive of chronic liver disease with portal hypertension in 80 patients (44%), fatty liver in 20 (11%) cases, and ascites with normal liver in 6 cases (3.29%). Other studies from south Asia revealed cirrhosis as less common association than that of our study.[11]
The endoscopic finding in present study showed varices were seen in 64 cases (35.16%) out of which 52 had esophageal or GOV and 12 had isolated gastric varices, duodenal ulcers (PUD) were seen in 31 cases (17%), gastric ulcer in 20 cases (11%), carcinoma stomach in 17 patients (9.34%), severe esophagitis with or without tear in 15 patients (8.24%), severe erosive gastritis in 12 cases (7.69%), MWT in 8 cases (4.39%), normal endoscopy 8 cases (4.39%), severe PHG without varices in 5 cases (2.74%). Earlier study by Kashyap et al. showed duodenal ulcer in 43.9%, gastric ulcer in 17.1% in contrast to our study. In our study, there was high prevalence of esophageal varices with included GOV I, but the incidence of isolated gastric varix was also high as compared to previous studies in India as well as south Asia.[7],[12],[13] Most of the patients with acute variceal bleed were managed endoscopically using endoscopic variceal banding as well as endoscopic sclerotherapy. All isolated gastric varices were treated using cyanoacrylate glue injection. Most of the patients with esophageal gastric varices, there was some degree of PHG, but five patients (2.74%) cases the endoscopic finding revealed severe PHG without any varix. Such cases were treated medically and also by Argon plasma coagulation. Hence, the most common cause of upper GI bleed was portal hypertension related bleeding (38%) which included esophageal varices, gastric varices, and severe PHG.
The second most etiology for UGI bleed was duodenal ulcers which contributed 17% cases (31). Most of these cases had associated melena as a symptom. All cases with active bleed were managed by endoscopic adrenaline injection therapy and intravenous proton pump inhibitors. The third most common cause of UGI bleed was gastric ulcers (nonmalignant) comprising 11% of cases. Gastric ulcer varies from 1.18% to 17.1% seen in various Indian studies.[7],[10],[12],[13] Almost 80% of gastric ulcer were present along lesser curvature near incisura. Out of all gastric ulcer biopsies 76% revealed Helicobacter Pylori positivity. All such cases were treated using standard triple therapy for 2 weeks. All these gastric ulcers were biopsied and HPE showing malignant ulcer was included in gastric cancer group. Our study revealed gastric cancer as a cause of upper GI bleed in 17 patients (9.34%). All those cancers were biopsy proven adenocarcinomas. We did not find any other gastric malignancy as a cause of upper GI bleed.
Other less common causes included severe esophagitis with or without tear in 15 patients (8.24%). Severe erosive gastritis in 12 cases (7.69%), MWT in 8 cases (4.39%). All these patients were managed conservatively. A total of 8 cases (4.39%) endoscopy did not yield any positive finding despite of a second look endoscopy to rule out any missed lesion.
The present study showed varices had earlier presentation compared to ulcer. The present study had most of patients of peptic ulcer in the age of 51–70 years, which is comparable to previous Indian studies. Most of the variceal bleed patients presented from 41 to 60 years.
| Conclusions | | |
From our study, we conclude that the most common cause of upper GI bleed in our part of India is portal hypertension related bleeding which included esophageal varices, gastric varices, and severe PHG. This was in contrary to most of the studies from other part of the country as peptic ulcer is far more common than variceal bleed in other studies. The most common age group with UGI bleed was 51–60 years and most of them were males. We also state that causes of UGIB vary from study to study and time to time, appropriate clinical judgment and early endoscopy should be considered in all patients of UGIB.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Anand CS, Tandon BN, Nundy S. The causes, management and outcome of upper gastrointestinal haemorrhage in an Indian hospital. Br J Surg 1983;70:209-11.  |
| 2. | Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: A population-based study. Am J Gastroenterol 1995;90:206-10. |
| 3. | Lanas A, Perez-Aisa MA, Feu F, Ponce J, Saperas E, Santolaria S, et al. A nationwide study of mortality associated with hospital admission due to severe gastrointestinal events and those associated with nonsteroidal antiinflammatory drug use. Am J Gastroenterol 2005;100:1685-93. |
| 4. | Ginn JL, Ducharme J. Recurrent bleeding in acute upper gastrointestinal hemorrhage: Transfusion confusion. CJEM 2001;3:193-8. |
| 5. | Shaikh N, Khatri G, Bhatty S, Irfan M. Endoscopic diagnoses in patients with upper gastrointestinal bleeding. Med Channel 2010;16:30-4. |
| 6. | Wuerth BA, Rockey DC. Changing epidemiology of upper gastrointestinal hemorrhage in the last decade: A nationwide analysis. Dig Dis Sci 2018;63:1286-93. |
| 7. | Kashyap R, Mahajan S, Sharma B, Jaret P, Patial RK, Rana S, et al. A clinical profile of acute upper gastrointestinal bleeding at moderate altitude. J Indian Acad Clini Med 2005;6:224-8. |
| 8. | |
| 9. | Ahmed MU, Ahad MA, Alim MA Uddin R. Etiology of upper gastrointestinal hemorrhage in a teaching hospital. J Teach Assoc 2008;21:53-7. |
| 10. | Singh SP, Panigrahi MK. Spectrum of upper gastrointestinal hemorrhage in coastal Odisha. Trop Gastroenterol 2013;34:14-7. |
| 11. | Chaikitamnuaychok R, Patumanond J. Clinical risk characteristics of upper gastrointestinal hemorrhage severity: A multivariable risk analysis. Gastroenterology Res 2012;5:149-55. |
| 12. | Krishnakumar R, Padmanabhan P, Premkumar SC, Ramkumar JA. Upper GI bleed- A study of 408 cases. Indian J Gastroenterol 2007;26:A133. |
| 13. | Rathi P, Abraham P, Jakareddy R, Pai N. Spectrum of upper gastrointestinal bleeding in Western India. Indian J Gastroenterol 2001;20:A37. |
[Figure 1], [Figure 2]
|
Search Pubmed for