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Tuesday, 26 November 2013

Upper gastrointestinal bleeding – The Risk Factors

The prevalence of upper gastrointestinal (GI) diseases is increasing in subjects aged 65 years and over. Pathophysiological changes in esophageal functions that occur with aging may, at least in part, be responsible for the high prevalence of
1. Gastro-esophageal reflux disease (GERD) in old age.
2. The incidence of gastric and duodenal ulcers and their bleeding complications is increasing in old-aged populations worldwide.
3.  H. pylori infection in elderly patients with H. pylori-associated peptic ulcer disease and severe chronic gastritis
4.  Almost 40% of GU and 25% of DU in the elderly patients are associated with the use of NSAID(1) and/or aspirin(2).(a)
IV. Upper gastrointestinal bleeding 
Upper gastrointestinal bleeding (UGIB) is defined as hemorrhaging derived from a source proximal to the ligament of Treitz. It is life threatening and considered as medical emergency, which is followed by high mortality rate, ranging from 6 to 15% in spite of modern diagnostic methods and treatment.
Risk factors
a. Medication
Medication such as aspirin, NSAIDs, warfarin, corticosteroids and SSRIs are associated with increase risk of upper gastrointestinal bleeding. In the study assess the impact of increased use of low-dose aspirin, other non-steroidal anti-inflammatory drugs (NSAIDs), warfarin, corticosteroids and selective serotonin re-uptake inhibitors (SSRIs) on the site and outcome of non-variceal gastrointestinal (GI) bleeds, researchers at the Lund University, Lund, Sweden, found that aspirin, warfarin and SSRI users tended to suffer more severe GI bleeds than non-users of these drugs. When comparing non-ulcer GI bleeds with PUBs, aspirin (OR 0.56, 95% CI 0.38-0.82) was more strongly associated with PUBs, whereas SSRIs (OR 3.71, 95% CI 1.39-12.9) and corticosteroids (OR 2.8, 95% CI 1.28-6.82) were more associated with non-ulcer GI bleeds after adjusting for age, gender and co-morbidity(11).

b. Acid reflux disease
Gastrointestinal (GI) complaints are common among athletes with rates in the range of 30% to 70%. Both the intensity of sport and the type of sporting activity have been shown to be contributing factors in the development of GI symptoms. Three important factors have been postulated as contributing to the pathophysiology of GI complaints in athletes: mechanical forces, altered GI blood flow, and neuroendocrine changes. As a result of those factors, gastroesophageal reflux disease (GERD), nausea, vomiting, gastritis, peptic ulcers, GI bleeding, or exercise-related transient abdominal pain (ETAP) may develop(12). For more information of gastroesophageal reflux disease (GERD), please visit
http://medicaladvisorjournals.blogspot.ca/2011/09/gastroesophageal-reflux-disease-gerd.html

c. Age
Upper GI bleeding was significantly correlated with age younger than 50 (P = .01) and male gender (P = .01; odds ratio, 3.13)(13).

d. Coagulopathy
Coagulopathy was prevalent in 16% of patients after nonvariceal upper gastrointestinal bleeding (NVUGIB). and independently associated with more than a fivefold increase in the odds of in-hospital mortality. Wide variation in plasma use exists indicates clinical uncertainty regarding optimal practice(14).

e. Etc.
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 Sources
(1a) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1065003/table/T1/ 
(1) http://www.ncbi.nlm.nih.gov/pubmed/22569978
(2) http://www.ncbi.nlm.nih.gov/pubmed/8202782

(11) http://www.ncbi.nlm.nih.gov/pubmed/20695720
(12) http://www.ncbi.nlm.nih.gov/pubmed/22897615
(13) http://www.ncbi.nlm.nih.gov/pubmed/9928705
(14) http://www.ncbi.nlm.nih.gov/pubmed/22897615