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Learning objectives

Upon completion of this activity, participants should be able to:

1. Describe the etiology and management of upper gastrointestinal bleeding in elderly adults.
2. Describe conditions that can cause sudden upper gastrointestinal bleeding in elderly adults.
3. Identify the most common cause of lower gastro-intestinal bleeding in the elderly.
4. Describe the etiology and management of lower gastrointestinal bleeding in elderly adults.
5. Specify diagnostic methods for obscure gastro-intestinal bleeding in the elderly.

Competing interests

The authors declared no competing interests. Charles P Vega, the CME questions author, declared that he has served as an advisor or consultant to Novartis, Inc.

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Clinical presentation, initial evaluation and immediate management

Patients with UGIB can present with vomiting of fresh blood (hematemesis) or of coffee-ground material, or with rectal passage of blood. Melena is suggestive of bleeding proximal to the ligament of Treitz but can be due to bleeding from more distal gastrointestinal sources, as far as the cecum. Rapid or high-volume UGIB can result in hematochezia. The initial manifestations of UGIB can include syncope, light-headedness, or postural hypotension, even in the absence of overt bleeding. Nasogastric intubation that returns a bloody aspirate can confirm the presence of UGIB. A clear or bilious nasogastric lavage, however, does not definitively exclude UGIB.

Medical history taking should include details of prior gastrointestinal bleeding, previous abdominal surgery and current medication use, particularly aspirin and other NSAIDs. The physical examination should begin with an assessment of hemodynamics, including postural changes. Physical findings of chronic liver disease are suggestive of underlying portal hypertension. Laboratory evaluation should include serum electrolyte and coagulation parameter measurements, liver biochemical tests and a complete blood count.

Hypotension at presentation is associated with high mortality among elderly people who present with peptic ulcer hemorrhage,¹¹ and early aggressive volume resuscitation decreases mortality.¹² Volume resuscitation in patients with acute UGIB should be aimed at maintaining adequate hemodynamics and end-organ perfusion. The patient's cardiopulmonary status should be monitored repeatedly during the course of aggressive volume resuscitation to assess for pulmonary edema or signs of right-sided heart failure. Prophylactic endotracheal intubation might be necessary in patients who have an altered mental status and ongoing hematemesis, to protect against aspiration.

Peptic ulcer disease

Peptic ulcer disease is the most common cause of UGIB, including in elderly people (Table 1).^{3, 5, 13, 14} The discovery of Helicobacter pylori, the recognition of the importance of gastric acid suppression in the early treatment of peptic ulcer hemorrhage, and the development of endoscopic hemostatic techniques have meant that since the 1980s the diagnosis and treatment of bleeding caused by peptic ulcer disease have improved. Data from the early 1980s, which cite high rates of rebleeding^{15, 16} and mortality^{16, 17} in older people with peptic ulcer hemorrhage, must, therefore, be interpreted with caution. Although the number of hospital admissions and operations for complications of peptic ulcer disease has declined for the overall population (including younger people) since the 1980s,^{18, 19, 20} rates of hemorrhage and hospital admissions have increased among elderly people with peptic ulcers.^{18, 19, 20} The trends among elderly patients might reflect the increasing rates of NSAID and anticoagulant use among the elderly.^{18, 20}

Table 1 Causes of upper gastrointestinal bleeding in the elderly.

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Platelet inhibition is impaired at an acidic gastric pH.²¹ Both platelet inhibition and mucosal fibrinolytic activity can be mitigated by gastric acid suppression.²² Treatment with a PPI is now the standard of care for patients with peptic ulcer hemorrhage and has been shown to decrease ulcer rebleeding rates independent of endoscopic therapy.²³ Long-term PPI use can be associated with impaired absorption of supplemental calcium²⁴ and with vitamin B₁₂ deficiency,²⁵ and one case–control analysis reported an increased risk of hip fracture.²⁶ There are, however, no data to suggest that elderly patients who receive short-term PPI therapy for acute UGIB experience these adverse effects.

Esophagogastroduodenoscopy (EGD) should be performed once a patient with UGIB has been hemodynamically resuscitated; our practice is to perform EGD within 12h of presentation. EGD can confirm the presence of peptic ulcer disease, identify stigmata that connote a risk of recurrent or continued hemorrhage, and permit endoscopic therapy to reduce the risk of rebleeding. Endoscopic therapy with an epinephrine injection, thermocoagulation, hemostatic clip placement, or a combination of these modalities, decreases rebleeding rates in patients with a spurting vessel, adherent clot (after removal of the clot), or visible vessel (Table 2).²⁷ Endoscopic therapy for peptic ulcer hemorrhage seems to be well tolerated in the elderly (Table 3).^{10, 28} Combining endoscopic therapy with PPI administration results in lower rebleeding rates than with endoscopic therapy alone.²⁹ Among patients who experience rebleeding, there are no data to suggest that age influences the timing of rebleeding.

Table 2 Peptic ulcer: endoscopic stigmata of rebleeding and mortality, with and without endoscopic therapy.

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Table 3 Peptic ulcer rebleeding and mortality by patient age.

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Hypovolemic shock at initial presentation, which is suggestive of massive ulcer hemorrhage, is associated with a poor outcome in the elderly.¹¹ Elderly patients who have ulcers of 2cm or more in diameter are at a particularly high risk of rebleeding and mortality.³⁰ Surgical therapy for peptic ulcer hemorrhage is reserved for patients who have hemorrhage that is refractory to pharmacologic and endoscopic therapy. Sepsis and multiorgan failure are leading causes of postoperative mortality in elderly people who undergo surgery for peptic ulcer hemorrhage. In one retrospective series of 136 elderly patients with peptic ulcer hemorrhage (median age 77 years), mortality was 31% among the 42 patients who underwent surgery; sepsis accounted for nearly 50% of these deaths.³¹

Esophageal varices and portal hypertensive gastropathy

Esophageal and gastric varices are caused by increased venous collateral flow from the portal circulation through the gastric coronary veins, usually because of portal hypertension. Variceal hemorrhage can occur when the hepatic venous pressure gradient exceeds 12mmHg. Features predictive of variceal hemorrhage include large variceal size and the presence of red 'wale' marks on varices.³²

The mortality of patients who present with variceal hemorrhage has historically exceeded 30%.³³ There are data to suggest that the mortality associated with variceal hemorrhage has improved over time, ostensibly as a result of advances in medical and endoscopic therapy; however, these data come from cohorts of patients with a mean age well below 65 years.^{33, 34} Available data suggest that mortality after variceal hemorrhage correlates with the Child–Turcotte–Pugh score (Child class) and not with advanced age.³⁵

Pharmacologic therapy for acute variceal hemorrhage generally includes intravenous administration of a somatostatin analog to reduce splanchnic circulation inflow. Cardiovascular effects can be observed in patients who take these medications; these effects include a decrease in heart rate (with terlipressin)³⁶ and peripheral vasoconstriction (with octreotide).³⁷ Although these effects have not been shown to correlate with adverse outcomes, elderly patients who are taking these medications should be carefully monitored.

Endoscopic variceal band ligation has supplanted injection sclerotherapy as the endoscopic therapy of choice because of the lower rate of complications.³⁸ Nonselective -blockers are effective for both primary and secondary prophylaxis of variceal hemorrhage; however, elderly patients should be monitored closely for adverse effects, which include orthostasis, fatigue, and affective disturbance.

Patients with portal hypertensive gastropathy (PHG) can present with or without endoscopically apparent gastroesophageal varices. If gastrointestinal bleeding occurs in a patient with PHG, it is more commonly chronic and occult than overt and hemodynamically significant.³⁹ Reduction of portal venous pressure with a nonselective -blocker might be beneficial for patients with PHG and gastrointestinal bleeding; however, the data to support this indication are limited as compared with those for variceal bleeding prophylaxis.

Clinical presentation, initial evaluation, and immediate management

In patients with LGIB, taking a detailed history is critical. The history can distinguish among possible etiologies of LGIB in elderly patients (Table 4). Characterization of the color, volume, and consistency of blood passed per rectum can help to localize a bleeding site. Passage of formed stool mixed with blood is suggestive of an anorectal bleeding source. The passage of melena is not exclusive to UGIB and can be seen when patients have proximal colonic bleeding sources. Cramping abdominal pain or abdominal tenderness suggests colitis.

Table 4 Causes of lower gastrointestinal bleeding in the elderly.

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The onset and pace of LGIB can provide additional clues as to the underlying etiology. The abrupt onset of painless, hemodynamically significant hematochezia (passage of bright red blood per rectum) is characteristic of diverticular hemorrhage. Bleeding from angiodysplasia, on the other hand, can vary in presentation from overt hemorrhage to chronic occult blood loss.⁵⁴

Anoscopy is recommended, in addition to a digital rectal examination, as a standard component of the initial physical examination in patients with LGIB to assess for anorectal pathology.⁵⁵ Nasogastric intubation and lavage can be useful, not only to evaluate for UGIB presenting as rectal hemorrhage, but also to rapidly purge the bowel in preparation for urgent colonoscopy.

The initial management of patients with LGIB should, in the same way as for patients with UGIB, emphasize hemodynamic stabilization. In contrast to UGIB, however, in which EGD is typically the diagnostic and therapeutic modality of choice, the range of diagnostic modalities available for patients with LGIB includes endoscopic, noninvasive radiologic, and angiographic options.

Diverticulosis

Most people who have colonic diverticulosis are asymptomatic and have an uncomplicated clinical course, but a small number of patients experience diverticular hemorrhage, which results from rupture of a vasa recta artery located in the wall of the diverticulum.⁵⁶ Angiographic data, now several decades old, have fueled the clinical belief that hemorrhage originates from right-sided diverticula;⁵⁷ however, diverticula in any colonic segment can be a source of bleeding. In most cases, and in more than 80% of cases in elderly people, diverticular hemorrhage ceases spontaneously.⁵⁸ Most cases of diverticular hemorrhage in elderly people can be managed nonsurgically, and overall mortality is less than 5%.⁵⁸ Massive or recurrent hemorrhage, however, can require a targeted intervention.

Flexible sigmoidoscopy or colonoscopy can be used to deliver endoscopic therapy, which includes epinephrine injection, thermal application,⁵⁹ or band ligation.⁵⁶ Skill and familiarity with epinephrine injection and a thermal technique should be in the armamentarium of all practicing endoscopists, whereas certain techniques, such as inversion and band ligation of a bleeding diverticulum, might be best reserved for experienced endoscopists at referral centers. In addition to the achievement of therapeutic hemostasis, the bleeding site should be tattooed to enable its ready localization in the event that repeat endoscopy or surgery is required.

Successful endoscopic therapy is contingent on visualization and identification of an actively bleeding diverticulum. This is especially difficult in patients with numerous diverticula throughout the colon, as is often the case. Additional hurdles to endoscopic therapy include impaired visualization caused by ongoing hemorrhage or inadequate bowel preparation. Moreover, hemorrhage can cease spontaneously before endoscopy. It is advisable to give a rapid purgative bowel preparation to patients who present with suspected acute diverticular hemorrhage to maximize the diagnostic and therapeutic yield.

Radiologic studies can be used as first-line investigative tools, or to evaluate patients who have ongoing or recurrent hemorrhage when endoscopic evaluation is unsuccessful. Technetium-labeled red blood cell scintigraphy can theoretically detect active gastrointestinal bleeding that occurs at rates as low as 0.1ml/min, although the sensitivity of the test may vary among institutions.⁵⁵ Use of multidetector CT angiography is an option available at selected centers. Some institutions require a positive scintigraphy result as a prelude to the performance of mesenteric angiography, a technique that can both locate a bleeding source and deliver targeted therapy (including intra-arterial vasopressin infusion or embolization). The often intermittent nature of diverticular hemorrhage means that scintigraphy and angiography can fail to detect the culprit lesion in patients with diverticular hemorrhage. Among patients with LGIB and a negative scintigraphy result, up to 25% will experience recurrent bleeding.⁶⁰

In a randomized, prospective study that has compared investigative modalities for acute LGIB, 100 patients with LGIB were randomly allocated to urgent colonoscopy or to technetium-labeled red blood cell scintigraphy followed by angiography; 67% of the patients were classified as having definite or presumptive diverticular hemorrhage.⁶¹ Colonoscopic therapy was delivered to 17 patients, whereas angiographic therapy was performed in 10 patients. There were no differences between the groups for key outcomes, which included early or late rebleeding rates, transfusion requirements, or the need for emergency surgery.⁶¹

Surgery is necessary in a minority of elderly patients who have persistent or refractory diverticular hemorrhage.⁵⁸ A critical decision is whether a presumptive bleeding source can be identified with sufficient confidence to permit segmental colonic resection. This identification can be a challenge in patients who have pan-colonic diverticular disease, in whom subtotal colectomy is an option. Emergency colonic resection confers higher mortality than elective surgery.⁶² An advanced age also seems to be associated with increased mortality in patients who undergo emergency colectomy for LGIB. One retrospective study reported 37% mortality for patients 70 years of age or older, compared with 21% for patients aged less than 70 years, among a subset of patients with LGIB who underwent emergency colectomy with primary anastomosis.⁶³

Ischemic colitis

Colitis of any etiology, including infectious colitis and idiopathic IBD, can be a source of gastrointestinal blood loss as a result of mucosal injury and sloughing.⁶⁴ The principal mechanism that underlies acute ischemic colitis—nonocclusive mesenteric ischemia—occurs primarily in the elderly. Episodes of ischemic colitis result from transient colonic hypoperfusion and can be precipitated by dehydration. Additional risk factors include small-vessel vascular disease (including vasculitis) and the use of certain medications, such as diuretics or vasoactive agents. The clinical presentation often includes cramping abdominal pain. Abdominal CT can demonstrate colonic wall thickening, and colonoscopy can demonstrate edema, friable mucosa, and submucosal hemorrhage in affected colonic segments.

Ischemic colitis is distinct from both chronic mesenteric ischemia (intestinal angina) and acute mesenteric ischemia caused by mesenteric arterial or venous occlusion. The incidence of ischemic colitis increases with age, and the disorder is associated with the presence of medical comorbidities, including hypertension⁶⁴ and dialysis-dependent chronic kidney disease.⁶⁵

The differential diagnosis of ischemic colitis includes infectious colitis, IBD, and drug-associated colitis.⁶⁴ Bleeding from ischemic colitis is rarely hemodynamically significant, and supportive care leads to full recovery in most patients. Patients with recurrent episodes can develop subacute colitis or stricture in the affected colonic segment. The presence of tachycardia, hypotension, or fever might suggest the presence of transmural colonic injury and impending bowel infarction. Death from ischemic colitis is uncommon, but mortality rate seems to increase with age and is associated with the presence of cardiovascular or cerebrovascular disease.⁶⁶

Other causes

Angiodysplasias

Angiodysplasias (also referred to as angioectasias) are a common source of gastrointestinal bleeding in the elderly. Although angiodysplasias are commonly located in the small intestine and colon,⁶⁷ and most are small and clinically inconsequential, an important minority located in the right side of the colon can cause massive hemorrhage.⁶⁸ An association between bleeding caused by angiodysplasias and acquired von Willebrand disease associated with aortic stenosis (Heyde syndrome) has been proposed but is controversial.⁶⁹ Affected individuals can experience either chronic occult blood loss or massive hemorrhage.^{54, 61} Endoscopic therapy can be targeted to actively bleeding lesions, but effective endoscopic therapy is difficult to achieve in patients who have numerous lesions or small-bowel lesions that are inaccessible to standard endoscopy. Single, large, bleeding angiodysplasias in the cecum can be particularly amenable to endoscopic, angiographic, or surgical therapy.

Hemorrhoids

Although the prevalence of hemorrhoids seems to decrease after age 65 years,⁷⁰ the association between hemorrhoids and constipation that is seen in younger patients persists in the elderly.⁷¹ Hemorrhoids can be detected during retroflexion in the rectum during an endoscopic examination, although anoscopy, which can easily be performed at the bedside in the early evaluation of rectal bleeding, might be required for optimal visualization.

Stercoral ulcer and solitary rectal ulcer syndrome

Stercoral ulcer and solitary rectal ulcer syndrome can result in massive rectal hemorrhage. Most patients with a hemorrhagic rectal ulcer are older than 60 years of age.⁷² Stercoral ulcers result from mucosal trauma caused by hard or impacted stool in the rectum or from a foreign body such as a rectal tube in a hospitalized patient. Solitary rectal ulcer syndrome is thought to result from rectal mucosal prolapse, also as a result of constipation and straining. When endoscopic stigmata of hemorrhage are identified in a rectal ulcer, hemostatic techniques analogous to those used in the endoscopic treatment of peptic ulcers can be applied.

Colonic neoplasms and post-polypectomy hemorrhage

Colonic neoplasms usually cause occult gastrointestinal blood loss, but patients with colonic neoplasms can also present with overt bleeding. Premalignant neoplasms (tubular adenomas) can be removed by polypectomy, and post-polypectomy hemorrhage, either early or delayed, occurs after a small fraction of polypectomies. One prospective analysis of nearly 10,000 polypectomies identified age greater than 65 years as a risk factor for post-polypectomy bleeding.⁷³

Radiation proctitis

Radiation proctitis occurs in people who have undergone radiation therapy for prostate, genitourinary, or gynecologic malignancies. It can develop years after treatment has ended, and can result in either overt rectal hemorrhage or chronic transfusion-dependent blood loss. Argon plasma coagulation,⁷⁴ formalin application,⁷⁵ sucralfate enemas,⁷⁶ and hyperbaric oxygen therapy⁷⁷ have been described as effective treatments for hemorrhagic radiation proctitis; however, comparative controlled data are limited, and it is not known which of these modalities is the most effective.

Video capsule endoscopy

Video capsule endoscopy (VCE, also known as wireless capsule endoscopy) has a diagnostic yield of 58–80% in patients with obscure gastrointestinal bleeding.^{79, 80, 81} In head-to-head comparisons, the yield of VCE is superior to push enteroscopy, small bowel enteroclysis, and mesenteric angiography.⁷⁹ Angiodysplasia is the culprit lesion most commonly identified by VCE.⁷⁹ In elderly people with impaired swallowing or delayed gastric emptying, the video capsule can be placed beyond the pylorus during EGD. VCE seems to be safe to conduct in people with permanent pacemakers⁸² and implantable defibrillators.⁸³

Double-balloon enteroscopy

Double-balloon enteroscopy (DBE) makes use of a modified enteroscope and overtube; both parts are equipped with a balloon that is inflated and deflated in sequential fashion to enable deep small-bowel exploration via either oral or rectal intubation. The diagnostic yield of DBE is 60–76% in patients with obscure gastrointestinal bleeding.^{80, 84, 85, 86} By use of DBE, the most commonly identified small bowel lesions in older patients are angiodysplasias; small bowel tumors are relatively more common in younger people.^{84, 86} Even though the procedure is time consuming and is more invasive than VCE, it allows for the possibility of therapeutic intervention. The age of patients in published studies of DBE ranges from 48 to 57 years,^{84, 85, 86} and the technique has not been performed extensively, nor its safety established, in elderly patients.

NSAIDs and gastrointestinal bleeding

Aspirin increases the risk of UGIB in a dose-dependent fashion.⁸⁷ The addition of a non-aspirin antiplatelet agent or NSAID to regular aspirin use has at least an additive impact on this increased risk.^{88, 89, 90} An increasing proportion of patients with UGIB report taking aspirin or other antithrombotic drugs.⁹¹ Taking aspirin and other NSAIDs also seems to confer an increased risk for LGIB, in particular diverticular hemorrhage.^{92, 93}

The increased risk of UGIB and LGIB associated with the use of aspirin and other NSAIDs is particularly pertinent to elderly people, many of whom require one or more of these medications for management of chronic cardiovascular or rheumatologic conditions. In elderly patients who require aspirin and have risk factors for gastrointestinal bleeding—including a prior history of gastrointestinal bleeding—aspirin should be prescribed in the lowest possible dose needed to achieve cardioprotection. The use of low-dose aspirin (e.g. 100mg per day) does not, however, eliminate the risk of bleeding (adjusted relative risk for UGIB=2.7 in aspirin users compared with nonusers⁸⁸). The long-term risk of UGIB in elderly patients who take aspirin can be reduced by concurrent administration of a PPI.⁹⁴

NSAID use might also be a risk factor for nosocomial gastrointestinal bleeding in elderly people. In a study of elderly patients (mean age 82.1 years) hospitalized for hip fracture, prior use of aspirin or a selective cyclo-oxygenase 2 inhibitor, and a history of peptic ulcer disease, were among the risk factors associated with the development of perioperative UGIB.⁹⁵ Prophylactic gastric acid suppression (with a histamine H₂-receptor antagonist or PPI) seems to reduce the frequency of nosocomial UGIB (0.72% in those receiving prophylaxis versus 13.4% in those not receiving prophylaxis) among patients with identified risk factors for perioperative UGIB.⁹⁵

Endoscopic safety

The relative safety of gastrointestinal endoscopy has been established in an average-risk population, and this has enabled the widespread acceptance of colonoscopy as a screening tool. Acute hemorrhage and intercurrent illness influence the safety of endoscopy in an individual patient. For instance, the mortality associated with EGD has been estimated to be 0.0004%,⁹⁶ but increases to 0.1% in patients undergoing EGD for evaluation of gastrointestinal hemorrhage.⁹⁷

Studies of EGD⁹⁸ or colonoscopy^{98, 99, 100} carried out in elderly patients report overall procedural success and morbidity similar to that reported for the general population; however, the indication for endoscopy in most patients in these studies was screening or surveillance, and a relatively small percentage underwent endoscopy for evaluation of acute gastrointestinal bleeding.

Factors likely to influence the morbidity and mortality associated with endoscopy in an elderly cohort with acute gastrointestinal bleeding include the acuity and severity of hemorrhage and the presence of comorbid conditions. The presence of certain anatomic lesions such as a Zenker's diverticulum or cervical spine osteophytes can increase the risk of perforation during upper gastrointestinal intubation in elderly people.¹⁰¹

Tolerance of sedation is an important consideration in elderly patients, who require lower doses of benzodiazepines than non-elderly patients of equivalent weight and body habitus.^{102, 103} Elderly patients prescribed benzodiazepines for sedation can be prone to oxygen desaturation during endoscopy.^{104, 105} Drugs used for sedation and analgesia should be administered at low doses to an elderly patient, with subsequent slow, careful titration. Continuous hemodynamic monitoring, use of pulse oximetry, and suction of oral secretions are necessary to safeguard against aspiration.¹⁰⁶

Cognition and the elderly patient

The prevalence of dementia increases with age.⁵¹ Even in the absence of clinical dementia, sensory impairment can affect cognition, and in an individual patient these factors can influence both the course of illnesses and interactions with health-care professionals. The clinician must pay particular attention to these issues during the evaluation, management, and aftercare phases of illness.

Although initial evaluation begins with clinical history taking, several factors can influence an elderly patient's ability to provide an accurate history at presentation. Relative cerebral hypoperfusion as a result of hemorrhage and hypovolemia can impair cognition in elderly patients. In other cases, sensory impairment can limit an individual's ability to provide a detailed history. The ability to describe the onset, acuity, and volume of rectal bleeding, for instance, requires intact vision and attention to the physical environment. When dementia or impaired memory prevents direct history taking from an elderly patient, family members or the patient's primary care physician can serve as valuable sources of information.

Dementia or a clouded sensorium can similarly influence the individual's ability to participate in decision making, provide informed consent for endoscopy, and generate a plan and goals of care. In these instances, either advanced directives or a formal health-care proxy can be instrumental. As with all patients, the risk–benefit analysis of an invasive medical procedure such as endoscopy must be performed on an individual basis for each elderly patient.

After stabilization and acute control of hemorrhage, an elderly patient's cognitive status must be carefully monitored; this approach is particularly relevant for patients who have received sedative medications for endoscopy. Certain elderly people depend heavily on regular environmental cues and can be prone to delirium during a hospital stay. An elderly patient's ability to care independently for himself or herself, or otherwise access appropriate support, will determine whether the patient can safely return home immediately after hospitalization.