What are the common causes of upper GI bleeding in elderly patients with severe anemia?

Common Causes of Upper GI Bleeding in the Elderly with Severe Anemia

In elderly patients presenting with upper GI bleeding and severe anemia, peptic ulcer disease (including gastroduodenal erosions and ulcers) represents the most common cause, followed by gastric and esophageal malignancies, with a significant proportion having dual pathology requiring evaluation of both upper and lower GI tracts. 1

Primary Upper GI Bleeding Sources

Peptic Disease (Most Common)

• Peptic ulcers, gastroduodenal erosions, and esophagitis collectively account for the majority of upper GI bleeding in elderly patients 2
• NSAID use is particularly relevant in this age group, though it does not reliably predict lesion location or type 2
• Aspirin and anticoagulant use compound bleeding risk from mucosal lesions 1

Malignancy

• Gastric and esophageal cancers are critical diagnoses not to miss, as they frequently present with iron deficiency anemia before overt bleeding 1, 2
• Neoplasms (both cancers and polyps) represent a substantial proportion of bleeding sources 2
• The prevalence of malignancy increases significantly with age, strengthening the case for complete evaluation 1

Other Important Causes

• Angiodysplasia should be considered, particularly in patients requiring transfusion or with recurrent bleeding 1
• Vascular malformations may require mesenteric angiography if standard endoscopy is unrevealing 1
• Rare causes include GIST tumors, though these are uncommon 3

Critical Consideration: Dual Pathology

Elderly patients have a 10-15% incidence of dual pathology (simultaneous upper and lower GI tract lesions), which increases with age 1. This means:

• Finding an upper GI lesion does not exclude the need for lower GI evaluation 1
• Only advanced gastric cancer or coeliac disease should deter immediate lower GI investigation 1
• One-third of patients with benign upper GI bleeding lesions have concurrent colonic pathology 2

Multifactorial Etiology in the Elderly

Iron deficiency in elderly patients is often multifactorial 1:

• Poor dietary intake and reduced iron absorption 1
• Medication effects (NSAIDs, aspirin, anticoagulants) 1
• Chronic disease (CKD, CHF) contributing to functional iron deficiency 1
• Multiple vitamin deficiencies (B12, folate) compounding anemia 1

Diagnostic Approach

Initial Evaluation

• Upper endoscopy reveals a cause in 30-50% of cases and should include duodenal biopsies to screen for coeliac disease (2-3% prevalence) 1
• Proceed with colonoscopy or CT colonography even if upper GI pathology is found, unless advanced gastric cancer is identified 1

Risk Stratification

• Use validated scores (Glasgow-Blatchford, Rockall) to identify high-risk patients 1, 4
• Elderly patients often have poor tolerance for anemia due to cardiovascular comorbidities 1

Management Priorities

Transfusion Thresholds

• Transfuse at hemoglobin <70 g/L in stable patients 1, 5
• Use higher threshold (80-100 g/L) in patients with cardiovascular disease (ischemic heart disease, heart failure) 1, 5
• Elderly patients with UGIB may require higher thresholds due to hemodynamic instability and poor anemia tolerance 1

Coagulopathy Management

• INR 1.3-2.7 does not predict rebleeding or mortality 1, 5
• Correct INR to <1.8 when possible, as this reduces mortality 1, 5
• Do not delay endoscopy for coagulopathy correction; proceed simultaneously 1

Common Pitfalls to Avoid

1. Assuming a benign upper GI lesion explains all bleeding—always evaluate the colon in elderly patients 1, 2
2. Attributing anemia solely to age or chronic disease—confirm true iron deficiency before dismissing GI investigation 1
3. Over-transfusing—restrictive strategies (Hb 70-90 g/L) reduce mortality and rebleeding in non-cardiac patients 5
4. Delaying endoscopy for minor coagulopathy—INR <2.5 is safe for endoscopic therapy 5