Acute gastrointestinal (GI) hemorrhage is a significant cause of morbidity and mortality in the emergency setting. The source of GI bleeding can range from the esophagus through to the colon and is classified into upper or lower GI bleeding depending on the site of bleeding relative to the ligament of Treitz. Upper GI hemorrhage occurs from sites proximal to the ligament of Treitz frequently due to peptic ulcer disease and variceal hemorrhage and accounts for more than 80% of acute bleeding.1 The majority of lower GI bleeding originates from the colon from pathologies such as diverticular disease and angiodysplasias. The small intestine is the site of hemorrhage in fewer than 5% of patients.1 Hemorrhage persisting or recurring after negative endoscopy is termed obscure bleeding. Occasionally patients present with occult bleeding, where there are no signs of overt bleeding, but the presenting symptoms are due to chronic blood loss and anemia. In all cases, thorough investigation to localize the source of bleeding allows rapid and often definitive management.
Incidence of Acute GI Hemorrhage
The annual incidence of acute upper GI hemorrhage is estimated at 170 cases per 100,000 adults, with an increasing incidence with age. The majority of cases are due to upper GI bleeding, with lower GI bleeding having an annual incidence of only 20.5 per 100,000 adults.2,3 There are geographical variations in the incidence, with reported rates varying from 45 per 100,000 in the Netherlands to 172 per 100,000 in Scotland. This difference is likely related to differences in population demographics and prevalence of various etiological factors between the countries.4–10
Despite advances in medical and endoscopic therapies, the mortality from upper GI bleeding remains unchanged at 5–14%,4,5,7–11 and is particularly high in the elderly and hospitalized.12 In fact, recent reports from the United Kingdom highlight an increase in the mortality rates of patients with upper GI bleeding, in part due to the aging population.
Acute GI bleeding exerts a massive drain on health care resources. Rectal bleeding was the 6th most common symptom and melena the 11th most common symptom requiring an outpatient clinic appointment in 2002,13 while colonic diverticular disease with hemorrhage was the 11th most common cause of inpatient admissions in 2002.13 Approximately 5% of surgery for diverticular disease was necessitated by massive bleeding.14 Diverticular bleeding has been estimated to cost over US $1.3 billion15 while upper GI bleeding exerts an even higher burden on health care systems, costing an estimated US $2.5 billion annually in the United States.16 Variceal bleeding incurred particularly high costs, with an estimated cost of $23,207 per admission for complicated variceal bleeding compared to $5632 for complicated nonvariceal upper GI bleeding. Uncomplicated cases cost $3402 per admission (nonvariceal upper GI bleeding) and $6612 per admission (variceal upper ...