[Acute massive gastrointestinal bleeding in the elderly]

Acute massive gastrointestinal bleeding appears to be becoming more frequent and complex in elderly patients with increasing longevity and a variety of diseases. because of long-term medication such as anti-thrombotic agents (ATA) for the prevention of cardiovascular diseases, anti-dementia drugs for the treatment of dementia, with increasing longevity and a variety of diseases. We, therefore, conducted a study to clarify these problems from a clinical view point in geriatric medicine.

The bleeding sites and the causes were studied in 85 consecutive patients with melena, hematemesis or acute blood loss, on the basis of clinical and emergency endoscopic findings.

The patients were aged 66 to 95 (40 men and 45 women), and the underlying diseases were mainly cerebral infarction in the chronic phase, osteoarthropathy, atrial fibrillation, and dementia. Ten patients had a previous history of peptic ulcer. As initial symptoms, melena, hematemesis and acute anemia were seen in 49, 18 and 18 patients, respectively. Based on assessable endoscopic findings n=83), the bleeding sites were a gastroduodenal ulcer, reflux esophagitis/acute gastric mucosal lesion, colon diverticulum, or alimentary tract cancers in 43.4%, 13.2%, 16.9%, and 16.9%, respectively. A total of 75 patients were treated with some medications (on average 5.3 kinds of medication per patient). Non-steroidal anti-inflammatory drugs (NSAIDs) and/or ATA were common in 63.5% of 85 patients; particularly two thirds of the patients with hemorrhagic gastroduodenal ulcer had used non-aspirin NSAIDs for treatment of osteoarthropathy or acute upper respiratory inflammation, and/or low-dose aspirin for prevention of vascular events. Patients taking ATA over a long period had bleeding from various sites. Steroids, acetylcholinesterase inhibitor (AchEI), selective serotonin-reuptake inhibitor (SSRI), and bisphosphonates were taken by 5, 9, 3 and 3 patients, respectively, frequently in combination with NSAIDs or ATA. Cerebral infarction occurred in 3 of 38 patients after withdrawal of ATA.

AchEI, SSRI and bisphosphonates, a newly developed group of drugs, have become widely available as geriatric medication. However, it appears that the incidence of drug-related gastrointestinal bleeding is extremely high not only in patients who underwent long-term treatment with NSAIDs or ATA, but also in patients treated chronically with AchEI, SSRI or bisphosphonates in combination with occasional use of NSAIDs. Therefore, to manage elderly patients safely, it is necessary to clarify both the drug and previous histories and consider NSAIDs use with caution even when they are indicated.