The Natural History of Hematemesis in the 21st Century

Abstract

Objective: Upper gastrointestinal (GI) bleeding occurs at a rate of 40-150 episodes per 100,000 persons per year and is associated with a mortality rate of 6%-10%. We sought to determine the need for therapeutic endoscopy or surgical interventions in patients with hematemesis and the association with blood transfusion requirements.Methods: We queried the database of our large teaching facility for adult patients presenting with obvious upper GI hemorrhage (hematemesis) between 2014 and 2017. We evaluated the amount of blood transfusions administered and the need for operative, endoscopic or angiographic interventions.Results: Eighty-one patients were admitted with hematemesis: mean age was 63 years old (range 21-103), 60% were male, and mean hemoglobin was 11.3 g/dL (range 3.6-15.6). Forty-one percent received blood transfusions with a mean of one unit transfused per patient (range 0-10); 9% received ≥ 3 units of packed red blood cells. Bleeding stopped spontaneously in 88% of patients and nine died. Forty-seven percent underwent inpatient endoscopy but only 6% underwent a therapeutic endoscopic intervention. No patient had a surgical or interventional radiologic procedure related to their GI bleed.Conclusion: Upper GI bleeding rarely requires operative or interventional radiologic intervention. Blood transfusions were not predictive of the need for therapeutic endoscopic intervention which was required in only 6% of patients.

Natural History of Patients Undergoing Therapeutic Endoscopies for Acute Gastrointestinal Bleeding

“…In general, surgery should be considered only after all other therapeutic options have failed. It is worth mentioning that transfusion requirements did not predict the need for therapeutic interventions in our previous investigations 3,4 or the need for a second intervention to control recurrent bleeding in our present study (Table 3).…”

“…Surgery or IR procedure was not required to control patients bleeding during the study period. 3,4 In light of these interesting results and data from other trials, we decided to study the natural history of GI hemorrhage in patients who have undergone therapeutic endoscopy. We found that most of our patients (91%) stabilized after therapeutic endoscopies, whereas a small group had recurrence of bleeding after the interventions (9%).…”

“…2 In previous studies, we have demonstrated that therapeutic endoscopy for control of acute GI hemorrhage is required in only 6 per cent of cases, whereas surgery and angiographic embolization have rarely been used. 3,4 In fact, more than 86 per cent of patients with acute lower GI bleeding stop spontaneously without the need for therapeutic endoscopic intervention. This is despite the fact that the mean number of packed red blood cells infused in these patients was greater than 2 units.…”

“…This is despite the fact that the mean number of packed red blood cells infused in these patients was greater than 2 units. 3,4 Angiographic intervention is rarely valuable in the setting of acute GI bleeding because the procedural complication rate is high and usually bleeding is not sufficiently brisk to allow for identification of the site of hemorrhage. The American Society for GI Endoscopy recommends that mesenteric angiography, with or without a preceding nuclear red blood cell scan, should be reserved for patients with severe bleeding who cannot be stabilized or prepped for a colonoscopy and for those who have failed endoscopic management.…”

“…6 In our retrospective studies, surgery was very rarely used for control of acute GI bleeding. 3,4 In this investigation, we sought to determine the natural history of acute GI hemorrhage in patients who have undergone therapeutic endoscopy. We hypothesized that therapeutic endoscopic interventions may have eliminated most of the necessity for surgery and/ or angiographic embolization in patients with acute GI bleeding.…”