Thursday, July 31, 2014

Resuscitation in the ED: Beyond the ABCs

Reuben Strayer, MD
, assistant clinical professor of emergency medicine at Mount Sinai Hospital in New York City, shares his expanded resuscitation mnemonic for the critical first 5 minutes. This talk originally appeared on and is lightly edited here. We last featured a talk by Strayer from AAEM 2014 about 10 ways to safely push ketamine in the ED.
Approaching a critically ill patient can be nerve-racking, and when your nerves are racked it can be hard to remember what to do. However, when you remember what to do, your nerves get less racked. So, I'm going to present a top-down approach to resuscitation that uses an expanded ABC's mnemonic to jog your memory and unrack your nerves:
DC3, A through J
For many years now, I go through this sequence in my head every time I'm confronted with a critically ill patent, and it makes me calm and organized, and a better doctor.
D for Danger
Danger to you the provider. Is it safe to approach the patient? In the emergency department this usually means protecting yourself from body fluid or airborne infectious diseases. Occasionally, there may be other concerns like the patient having something dangerous on their clothes or skin requiring decontamination. We deal with agitated or potentially violent patients all the time.
Like many of these bullet points, this is a talk unto itself, but from the perspective of resuscitation, if a critically ill patient is too agitated to be properly assessed, it is an absolutely crucial lifesaving maneuver to immediately and aggressively sedate.
There are a variety of effective agents I recommend: Droperidol, midazolam, and ketamine. If an IV is not yet available the agents should be given IM or IO.
The first C in C3 is "Call for help," move the patient to resus, call for your defibrillator, crash cart, airway cart, or whatever else is indicated. In big centers, you generally want more nurses and tech than usually show up and fewer doctors than usually show up.
Now that everyone is in the room you have to get them to be quiet. The second C is "Calm." Noise and shouting raise the ambient catecholamine level which makes it harder to take care of the patient. A forceful "Quiet please!" is usually all that's necessary to take everyone down a few notches. In big centers, there are usually too many people in the resus room when the patient arrives. Big resus cases are good for learning and occasionally someone in the peanut gallery has a good idea -- occasionally -- so I don't like to ask folks to leave the room.
Get them away from the action by announcing something like, "If you are not directly taking care of the patient please move to the perimeter of the room." If there is an orthopedist hanging out, he won't know the word "perimeter," so try "Please move away from the bed."
This is the time to determine who the resus leader is; if you're not sure, maybe it's you. All right, now that we've established the conditions in which the patient can be properly resuscitated, it's time to resuscitate the patient.
The third C in C3 stands for "Cardiac Arrest." Cardiac arrest has to be recognized straight away and is surprisingly easy to miss especially in a patient who arrives intubated by EMS. The first two priorities in cardiac arrest areimmediate uninterrupted high-quality chest compressions and defibrillation of v-fib and pulseless v-tach.
Cardinal ABCs
Now, we start in with the cardinal ABCs and A is of course "Airway." Our question is whether the patient needs an airway intervention. To answer this question, start with the patient's voice. The patient speaking comfortably with a normal voice is very unlikely to require an airway maneuver in the immediate term. Patients who are not speaking, demonstrate a patent and defended airway by handling their secretions.
Drooling and gurgling, coughing and gagging, are your clue that you may have an airway problem. But do not elicit a gag reflex as a way to test airway integrity. It's inaccurate and may induce vomiting and is exactly the person you do not want to vomit. Stridor is another sign and patients with a good level of consciousness and an airway obstruction may assume an airway posture, which is sniffing position.
Sometimes, the patient just needs repositioning of the head, but this is also the time to suction out the oropharynx, place oral or nasal airways or even an LMA if indicated, and determine if intubation is required or soon will be. If so, call for medications if needed and prepare for definitive airway management.
Move on to "Breathing," which is oxygenation and ventilation. Do yourself and patients a favor and put a nasal cannula on every critically ill patient from the start and then any additional oxygen or ventilation on top of that. Unless the patient is truly crashing, I apply the nasal cannula and keep the wall-oxygen off until I get a room air oxygen saturation, which provides much more information about oxygenation and ventilation than a saturation with supplemental oxygen.
Ventilate the patient if needed. Your initial exam maneuvers are pulse oximetry, respiratory rate, effort, and then breath sounds. Auscultating the lungs is a reflex action taken by many junior clinicians as a response to a distressed patient. I think that's because it makes it seem like you're doing something when you don't know what to do. In most cases, listening to the lungs is not helpful and is always less important than evaluating oxygenation and ventilation using respiratory effort and saturation. What you're listening for is air entering both sides, and the presence of wheezes or crackles. This should take no longer than seven second -- 3.5 seconds per lung.
Therapies to consider in the first five minutes relevant to breathing include needle finger or tube or ostomy, albuterol, epinephrine, or nitro. Call for a portable chest x-ray if indicated.
The initial "Circulation" priorities include immediate establishment of either intravenous or intraosseous access, measurement of heart rate and blood pressure, which is usually accomplished by putting a patient on a monitor, and the assessment of the adequacy of perfusion, feel for pulses, and assess the skin at the hands and feet. Immediate therapies to support circulation include IV fluids and uncrossed matched blood products and call for EKG when indicated.
Hyperkalemia is so common and so dangerous it should specifically be considered in a primary survey. C can also stand for "Calcium" in a critically ill dialysis patient with bradycardia or a wide complex rhythm.
D for Neurologic Disability
In the first phase of resuscitation, this calls for four maneuvers. Assessment of level of consciousness, usually using a responsiveness scale like GCS as well as the quality of the patient's mentation. Agitation or confusion are as important as decreased consciousness. Measure the pupils and their response to light. Determine movement at four extremities and rule out or treat hyperglycemia.
We don't have a problem with getting to do head CTs, but to be complete I must mention that this is the time to consider a STAT brain scan.
E for Exposure
Remove all clothing. And visualize every inch of skin. It is ideal if you can get this done at the initial assessment. It really sucks when the ICU team comes down and pulls the nitro patch off your hypotensive patient. Have someone check the pocket for pill bottles, the pacemaker wallet card, or a summary of their medical history. Use the opportunity to do a rectal temp if needed, and initiate active cooling or warming if indicated.
F Stands for Family and friends
If the history isn't clear, get a better story. Ask about goals of care, if appropriate. Give the patient's family an update on a patient's status within a cautious prognosis. If you say, "I'm very concerned about grandma," and she does well that's not a big problem. In fact, it makes you look like a very skillful doctor. If you say, "Grandma is doing great," and the next time the family sees her they have to unzip a body bag, you're not going to get a rave review on If the family is outside the resus area, ask them if they wish to be present during the resuscitation.
G Is for Analgesia
Do not forget to treat your patient's pain. I have looked back at many resuscitations and realized the only thing I did that actually helped the patient was morphine. Give it early and in appropriate doses: IV, IM or IO. If hypertension is a concern use fentanyl. If you don't have a line in a child, intranasal fentanyl is very effective. And for the patient in severe pain, adding an analgesic dose of ketamine is magic.
H Is for HCG
This is easy to forget and pregnancy changes everything. The bedside urine HCG assay works just as well with two drops of whole blood or capillary blood from a finger stick. In the clearly gravid female who is hypotensive, push the uterus to the left, And if she is dying or dead, consider a perimortem C-section. Don't worry about how many weeks or how many minutes mom has been arrested -- perimortem cesarean section is for mom more than for baby.
I Is for Infection
Consider whether the patient should be isolated, and do not delay the administration of broad spectrum antibiotics in a patient thought to be critically ill from an infection. If source control is required, this needs to be done expeditiously.
J Is for Ultrasound Jel
The last part of the first 5 minutes is ultrasound. Let me know if you have a better way of getting the word ultrasound to work with the letter J. All patients with hypotension of unclear etiology should have a comprehensive point of care ultrasound for shock. There is an ever expanding list of indications of point of care ultrasound. Get the probe on the chest early in a critically ill patient.
There is another C I left out: If you are using a mnemonic to study for oral board exams, add one more C after Cardiac Arrest -- as in C for spine immobilization collars. These have minimal if any utility in few, if any patients, and certainly cause harm, but we're probably a long way away from standard of care catching up to science in this domain. So if you're resuscitating a patient while wearing your best suit seated uncomfortably in a hotel across from somebody with gray hair who doesn't want to be there any more than you, add a C for C spine precautions.
In real life for the first 5 minutes of resuscitation: DC3, A through J.

Vitamin D Blog: Nutrient or Hormone?

Few people view their vitamin D supplement as hormone replacement therapy, but that's exactly what it is, experts told MedPage Today.
The weight of the literature suggests that vitamin D is indeed a hormone, not a nutrient, said Michael Holick, MD, PhD, of Boston University.
"By definition, vitamin D is a hormone," Holick told MedPage Today. "The body synthesizes it after sun exposure, and it's activated by the liver and kidneys. That activated form again acts like a hormone to regulate calcium metabolism."
No other vitamin goes through the process of activation that D does before it can be used by the body, Holick said. First, the skin must synthesize vitamin D3, or cholecalciferol, after exposure to UVB radiation. D3 is then metabolized by the liver into 25-hydroxyvitamin D, or 25(OH)D, and then moves on to the kidney where it is converted to the biologically active form 1,25-dihydroxyvitamin D, or 1,25(OH)2D.
"D3 is the prohormone, 25(OH)D is the major circulating form, and 1,25(OH)2D is the hormonally active form," Holick said, adding that vitamins A and C do get metabolized, but they don't need to be activated the way D does.
But vitamin D's status as a hormone rather than a nutrient raises questions about the way companies use it to fortify foods, said Marion Nestle, PhD, MPH, a food policy expert from New York University.
Nestle recently submitted comments to the FDA on its proposed changes to the Nutrition Facts panel on foods, arguing that companies shouldn't be permitted to tout vitamin D fortification without more context or details.
"Vitamin D fortification must be understood as a form of hormone replacement therapy," Nestle wrote on her blog. "As such, it raises questions about efficacy, dose, and side effects that should be asked about all such therapies."
She notes that D is found naturally in very few foods -- fish is one exception -- and even then it only exists in small quantities.
"It is present in most foods as a result of fortification," she said.
Holick disagreed that its status as a hormone should give people pause over vitamin D supplementation, because D deficiency affects such a large proportion of the population. Thus, a national hormone replacement therapy program would only provide benefit, he said.
"It's reasonable to have on the label," Holick said, "because everyone should be taking steps to increase their vitamin D intake." Though Holick's prescription is simpler -- 15 minutes a day in the sun should do the trick for sufficiency.

Wednesday, July 30, 2014

Is That App FDA Approved? Mobile Health Tech Falls Into Gray Area


The iHealth MyVitals app and a mobile blood pressure monitoring dock.

By Bahar Gholipour, Staff Writer for LiveScience 

Personal health is becoming increasingly mobile, and there are now thousands of apps aiming to address everything from lifestyle issues to chronic diseases. But can you trust these apps the same way you trust your prescribed drugs and medical devices?
Medical devices are generally regulated by the U.S. Food and Drug Administration, and although the FDA reviews some apps, experts say the agency's power and efforts aren't nearly enough to cover the 97,000 and counting health apps out there that are transforming consumer health.
"The FDA is woefully understaffed and under-resourced to oversee these things, particularly given the number of the thousands of apps that are [most likely] under FDA's jurisdiction," said health law expert Nathan Cortez, an associate professor of law at Southern Methodist University Dedman School of Law in Dallas, Texas.
In an editorial published in The New England Journal of Medicine on July 24, Cortez and his colleagues argued that health and medical apps hold the promise of improving health, reducing medical errors, avoiding costly interventions and broadening access to care. But to reach their potential, these products have to be safe and effective, they said.
A large number of health apps, such as those that help you track your exercise or the calories in your meals, likely don't pose a concerning risk to consumers. But in more ambitious apps, such as an app to manage insulin doses for diabetic patients, any mistake, bug or misinformation could simultaneously affect thousands of patients, and emerging evidence reveals many products do not work as claimed, or the products make mistakes.
"Early studies evaluating whether these apps work or not tend to paint a pretty dim picture of them. The results aren't that promising," Cortez told Live Science.

Which apps need to be regulated?

In September 2013, the FDA gave its position on what types of products and technologies would fall under its jurisdiction. Currently, the agency has a pre-market review process for some apps, meaning that the app developer submits information to the agency to get the FDA's blessing, Cortez said. The agency also sometimes takes enforcement actions by issuing a public reprimand to a company if its products violate FDA's rules and regulations.
So far, the FDA has cleared about 100 medical apps over the past decade, with about 40 of these approvals coming in the past two years, according to the agency. These apps are mobile forms of traditional medical devices, or are accessories to a regulated medical device. For example, one app evaluated lets physicians see data from electrocardiograms, and another offers medication reminders and connects patients with their doctors.
Still, the FDA's jurisdiction is limited, and the line between what constitutes a medical app and what is just about health and fitness could be blurry, which is frustrating for developers, Cortez said.
Although a number of laws have been proposed in Congress that aim to change the FDA's regulatory approaches, none have passed so far. One of the main arguments against expanding the FDA's oversight is that too much regulation would stifle innovation in the mobile health industry.
But Cortez said that this common refrain is shortsighted. "If you let these apps proliferate without any real oversight or any real enforcement, I think you risk consumer confidence in these products becoming really low," he said. "If the majority of apps don't work, and make claims that aren't substantiated, I think that will undermine the market in the long run."
Clear and decisive rules by the FDA could help mobile health technologies mature into the next generation that actually fulfill all the promises that the industry has for these products, Cortez said.
"It looks like Congress is building momentum towards some kind of legislation, some type of bill actually passing," Cortez said. If Congress does pass a bill, it should give the FDA more resources and push the agency to provide clear, binding rules for these products, he said. "I think that'll help the industry in the long term."

Should you trust the medical apps on your phone?

Mobile health and medical technology apps are still in the early stages, but for every few hundred that don't do anything, there are several apps that are actually helpful.
People who would like a useful app for their health condition should make sure that the app is reputable, has been updated and doesn't have bugs. They should also keep an eye out for recalls and look for FDA-cleared apps, Cortez said.
"For example, if I had diabetes, and I was looking to use an app, I would definitely try to use one that the FDA has cleared in pre-market review process over one that hasn't been cleared," Cortez said.
However, Cortez noted that even though the products may have gone through the FDA's clearance process, they haven't been tested as rigorously as new drugs and medical devices.
"I would also make sure my doctor knew what I was doing," Cortez said. "It would be a joint decision with the doctor."
This article originally published at LiveScience here

Wednesday, July 16, 2014

Gastrointestinal bleeding in the elderly


Gastrointestinal bleeding affects a substantial
number of elderly people and is a frequent indication for
hospitalization. Bleeding can originate from either the upper or lower
gastrointestinal tract, and patients with gastrointestinal bleeding
present with a range of symptoms. In the elderly, the nature, severity,
and outcome of bleeding are influenced by the presence of medical
comorbidities and the use of antiplatelet medication. This Review
discusses trends in the epidemiology and outcome of gastrointestinal
bleeding in elderly patients. Specific causes of upper and lower
gastrointestinal bleeding are discussed, and recommendations for
approaches to endoscopic diagnosis and therapy are given.


More than 1% of people aged 80 years and older are hospitalized each year because of gastrointestinal bleeding.1
Gastrointestinal bleeding in such elderly people can originate from
lesions common to all age-groups or from lesions associated specifically
with aging. In elderly people, morbidity and mortality from
gastrointestinal bleeding is determined by both the nature of the
bleeding lesion and the presence of comorbid medical conditions. The
incidence and outcome of gastrointestinal bleeding in elderly people can
also be influenced by the use of aspirin and other antiplatelet and
anticoagulant agents.

Gastrointestinal bleeding can be classified
as acute (presenting as hematemesis, melena, or hematochezia), or
chronic, suspected because of the detection of occult gastrointestinal
blood loss or anemia. Initial assessment of a patient with suspected
gastrointestinal bleeding must include determination of the acuity and
pace of blood loss. Subsequent clinical evaluation is undertaken to
identify the source of the bleeding. Once a bleeding source has been
identified, directed pharmacologic, endoscopic, and non-endoscopic
therapy can be offered.

This Review provides an approach to the
evaluation and management of gastrointestinal bleeding in the elderly.
Although the approach to the diagnosis and management of
gastrointestinal bleeding is not specific to elderly people, elderly
people with gastrointestinal bleeding differ from younger people with
the same condition with respect to several aspects of clinical
presentation and outcome (Box 1).
For the purposes of this Review, we define 'elderly' somewhat
arbitrarily as older than 60 years of age. The term 'very elderly' is
defined as an age greater than 85 years, a cutoff that might be more
clinically relevant as the health of the aging population improves. This
article also reviews the epidemiology and pathogenesis of the main
causes of gastrointestinal bleeding in the elderly—peptic ulcer and
diverticular hemorrhage, in particular, are discussed in detail with
special reference to the elderly population. Attention is also focused
on the utility and safety of endoscopic techniques for the diagnosis of
gastrointestinal bleeding in the elderly—including reference to emerging
techniques for small-bowel evaluation—and on the role of aspirin and
other NSAIDs in gastrointestinal bleeding in the elderly.

Box 1 Clinical features of upper gastrointestinal bleeding in elderly versus younger patients.


  • Presenting manifestations of bleeding: hematemesis (50%); melena (30%); hematemesis and melena (20%)
  • Peptic ulcer disease most common etiology
  • Safety and efficacy of endoscopic therapy
Differences (in elderly patients)

  • Fewer antecedent symptoms (abdominal pain, dyspepsia, heartburn)
  • Prior aspirin and NSAID use
  • Presence of comorbid conditions
  • Higher rates of hospitalization
  • Higher rates of rebleeding (peptic ulcer, see Table 2)
  • Higher mortality rate
With permission from Elsevier Ltd © Farrell JJ and Friedman LS (2000) Gastroenterol Clin North Am: 1–36.
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Upper gastrointestinal bleeding

gastrointestinal bleeding (UGIB) is defined as gastrointestinal blood
loss that originates proximal to the ligament of Treitz. Although the
overall incidence of nonvariceal UGIB seems to have declined since the
time trend analyses suggest that people aged over 60 years and over 80
years each constitute an increasing proportion of those presenting with
acute UGIB.3 As many as 70% of acute UGIB episodes occur in patients older than 60 years,4 and the incidence of UGIB increases with increasing age.5, 6 Advanced age has been consistently identified as a risk factor for mortality among patients presenting with UGIB,3, 5, 7, 8 presumably because of the high prevalence of comorbid illnesses—including pulmonary9 and cardiovascular10 disease—in elderly as compared with younger patients with UGIB.

Clinical presentation, initial evaluation and immediate management

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 rebleeding15, 16 and mortality16, 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

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

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.
Full tableFigures & Tables indexDownload PowerPoint slide (76K)
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

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

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 beta-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

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 beta-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.

Other causes

Esophagitis and gastropathy
and gastropathy describe mucosal injury to the esophagus and stomach,
respectively, and are most commonly caused by gastric acid or specific
medications, such as NSAIDs. Although overt hemorrhage is an uncommon
manifestation of esophagitis or gastropathy, these lesions are
implicated as bleeding sources more frequently in elderly than in
younger people.14, 40, 41, 42 Moreover, severe esophagitis might not be heralded by heartburn in elderly people.42
Esophagitis and gastropathy are not typically amenable to endoscopic
therapy unless a single ulcer with hemorrhagic stigmata is identified.
Therapy for these two conditions consists of agents to suppress gastric
acid secretion and the avoidance of offending medications, particularly
aspirin and other NSAIDs. Stress-related gastric mucosal injury can
result in UGIB in critically ill patients in an intensive care unit;
risk factors include mechanical ventilation, multiorgan failure, and
coagulopathy, but not advanced age.

Gastric antral vascular ectasia
with gastric antral vascular ectasia (also known as 'watermelon
stomach') typically present with occult or subacute blood loss and
transfusion-dependent anemia. The prevalence of gastric antral vascular
ectasia does not increase with age per se, but the condition can be associated with certain medical comorbidities, including end-stage renal disease43
and cirrhosis. Ablation therapy with argon plasma coagulation can
stabilize hemoglobin levels and ameliorate transfusion requirements;44 multiple treatment sessions may be required.

Aortoenteric fistula
An aortoenteric fistula (AEF) develops in 0.5% of patients who have undergone aortoiliac bypass surgery.45
An AEF can also develop after endovascular aortic repair, a procedure
that is being performed with increasing frequency in the elderly.46 AEF has been described in patients with native anatomy and after enteral stent placement.47 Both mechanical and inflammatory factors have a role in the development of an AEF.

a large retrospective series, the median time interval from an aortic
intervention to the development of an AEF was 90 months.48
The classic presentation is with a herald (sentinel) bleed followed by
exsanguinating hemorrhage. An AEF typically involves the third portion
of the duodenum but can occur anywhere throughout the gastrointestinal
tract, including the esophagus and colon.48 The median time to diagnosis of an AEF after presentation is approximately 10 days.45 Perhaps because of this delay, short-term mortality exceeds 30% even after accurate diagnosis and repair.48
Noninvasive imaging with CT angiography can enable the diagnosis of an
AEF, whereas mesenteric angiography is often not helpful and is not
generally indicated. Endoscopy can also be diagnostic and should include
careful examination of the third portion of the duodenum for an ulcer,
erosion or hematoma, or for visualization of graft material. Biopsy
samples should not be taken, and there is no role for endoscopic

Dieulafoy lesion
A Dieulafoy lesion is a dilated
submucosal artery that can rupture and result in overt gastrointestinal
hemorrhage. These lesions can occur in, but are not specific to, elderly
people. They are often found in the cardia of the stomach but can be
found throughout the gastrointestinal tract.49
As the lesions are surrounded by normal musosa, endoscopic diagnosis is
challenging unless performed at the time of active bleeding. Patients
can, therefore, present with recurrent hemorrhage before a diagnosis is
made.49 Either endoscopic or angiographic therapies can be applied.
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Lower gastrointestinal bleeding

incidence of lower gastrointestinal bleeding (LGIB) is less than that
of UGIB but also increases with age. One retrospective study estimated a
greater than 200-fold increase in the incidence of LGIB from the third
to the ninth decade of life.50 The mean age of people with acute LGIB ranges from 63 to 77 years.51
This trend is driven by the age-associated increase in the incidence of
diverticular hemorrhage, which is the most common cause of LGIB in
elderly people.1, 52 Compared with younger patients with LGIB, elderly people with LGIB incur longer hospital stays and greater health-care costs.53

Clinical presentation, initial evaluation, and immediate management

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.

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

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.


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.

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

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

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

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

Ischemic 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

(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
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

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
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
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
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.
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Obscure gastrointestinal bleeding

gastrointestinal bleeding is defined as bleeding from a source that
remains undetermined after EGD and colonoscopy. Sources of obscure overt
hemorrhage can include lesions that were missed78
or not actively bleeding at the time of initial endoscopy. In instances
of acute, overt hemorrhage, repeat endoscopy, scintigraphy, or
angiography can be considered. Alternatively, bleeding can originate
from a small bowel source beyond the reach of standard endoscopic
examination. New endoscopic technologies have an increasing role to play
in the investigation of small bowel bleeding. Two such techniques are
video capsule endoscopy and double-balloon endoscopy.

Video capsule endoscopy

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

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.
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Special topics

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

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

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

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 colonoscopy98, 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.

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

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

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.

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.
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bleeding occurs frequently in elderly people, and aspirin and
antiplatelet therapy are associated with an increased risk of both UGIB
and LGIB in this population. Knowledge of the gastrointestinal lesions
likely to affect elderly patients, thorough history taking, and a
complete physical examination should help to determine whether the
bleeding source is from the upper or lower gastrointestinal tract. In a
patient with acute gastrointestinal bleed-ing, hemodynamic stabilization
should always precede endoscopic evaluation. In elderly patients with
acute hemorrhage, urgent endoscopic evaluation can be undertaken,
provided a risk-benefit assessment has been performed and informed
consent has been obtained.

The most common source of UGIB in
elderly people is peptic ulcer disease. EGD is the investigative study
of choice for the evaluation of UGIB, and can be performed safely in
elderly people. EGD can identify a bleeding source, deliver targeted
hemostatic therapy, and provide estimates of the likelihood of recurrent
bleeding in patients with peptic ulcer disease. Pharmacologic gastric
acid suppression promotes ulcer healing and reduces the risk of

Diverticular hemorrhage is the most common source of
LGIB in the elderly. In an elderly patient with LGIB, urgent colonoscopy
should be performed after administration of a purgative bowel
preparation. If colonoscopy is suggestive of active bleeding but fails
to isolate a bleeding source, mesenteric angiography can be performed.
If colonoscopy does not detect active bleeding, the patient should be
maintained on a clear liquid diet. If there is evidence of acute (within
24–48h) recurrent hemorrhage, colonoscopy can be repeated or
angiography performed. Early surgical consultation is advisable in any
patient who has massive or recurrent LGIB, irrespective of age.

patients with a suspected small-bowel bleeding source, VCE has emerged
as the initial diagnostic study of choice. Review and interpretation of
VCE findings should be feasible within 24h of image acquisition, thereby
enabling timely management in cases of ongoing acute hemorrhage.

care of elderly people with gastrointestinal bleeding can involve
internists and intensivists, as well as gastrointestinal, surgical, and
radiologic consultants. A coordinated approach to diagnosis and
management should serve to optimize favorable outcomes in this
vulnerable patient population.

Key points

  • In
    elderly patients who have gastrointestinal bleeding, immediate
    attention should focus on hemodynamic stabilization, followed by
    diagnostic evaluation to identify the bleeding source
  • The
    outcome of gastrointestinal bleeding in elderly patients is influenced
    by the nature of the bleeding lesion, presence of medical comorbidities,
    and use of anticoagulant or antiplatelet therapy
  • Peptic ulcer
    disease is the most frequent source of upper gastrointestinal bleeding
    in elderly patients; gastric acid suppression with a PPI and endoscopic
    hemostatic therapy reduce the rates of rebleeding and morbidity
  • Diverticulosis
    is the most frequent source of lower gastrointestinal bleeding in
    elderly patients, and urgent colonoscopy can be undertaken to identify a
    bleeding site and provide hemostasis; emergency colectomy is associated
    with high morbidity and mortality in elderly patients who have
    persistent or recurrent diverticular bleeding
  • Video capsule
    endoscopy and double-balloon enteroscopy offer expanded options for
    diagnosis and therapy of small-bowel bleeding sources
  • Endoscopy
    can be performed safely and effectively in elderly patients with
    gastrointestinal bleeding; however, risks and benefits must be
    considered carefully in each case, with particular attention paid to the
    tolerance of procedural sedation