Management of upper gastrointestinal bleeding

As the number of elderly Americans dramatically increases over the next three decades, as the amount of NSAID usage in the elderly continues to increase, and as the incidence of ulcer disease continues to increase in the elderly, upper gastrointestinal endoscopy will play an increasingly important role in the management of gastrointestinal hemorrhage. Initial efforts should be directed toward stabilizing the patient and obtaining a history and physical examination. As the number of associated diseases increases in a patient with gastrointestinal hemorrhage, so does risk of mortality. Therefore, it is important to promptly identify the site of bleeding and to stop active or recurrent bleeding by the application of endoscopic therapy. Intravenous sedation should be given cautiously to achieve conscious sedation in a monitored patient. A skilled endoscopist should be available to perform endoscopy and apply the therapeutic modalities of electrocoagulation, photocoagulation, or injection therapy for bleeding or nonbleeding vessels or sclero-therapy for esophageal varices. The key to success is to identify the site of bleeding and then act on the finding as clinically indicated. By doing so, it appears that the cost of hospitalization and the mortality in the elderly patient are reduced.