Most Common Cause of Massive GI Bleeding in a 60-Year-Old Man
Peptic ulcer disease is the most common cause of massive gastrointestinal bleeding in a 60-year-old man presenting to the emergency department, accounting for 35-50% of nonvariceal upper GI bleeding cases. 1, 2
Primary Etiologies by Frequency
Upper GI bleeding accounts for approximately 85% of all acute GI bleeding presentations, making it the most likely source in this patient. 3
Most Common Causes (in order of frequency):
Peptic ulcer disease (duodenal and gastric ulcers) represents the leading cause at 35-50% of cases, typically related to Helicobacter pylori infection or NSAID use 1, 2
Gastric erosions and stress-related mucosal disease occur in 8-15% of cases, with markedly higher incidence in critically ill patients 2
Mallory-Weiss tears contribute approximately 15% of upper GI bleeding episodes, resulting from forceful vomiting or retching 1, 2
Esophagitis accounts for 5-15% of bleeding cases 2
Esophageal varices occur more frequently in patients with cirrhosis and carry high mortality risk 1
Age-Specific Risk Factors
In a 60-year-old patient specifically, several factors increase bleeding severity and mortality risk:
Age >60 years is an independent risk factor for mortality, with deaths rare under age 40 but increasing substantially with advancing age 4
Comorbidities (cardiac disease, renal failure, liver disease, disseminated malignancy) dramatically worsen prognosis and are more prevalent in this age group 4
NSAID use and H. pylori infection are the most prevalent etiologic factors, with bleeding risk increasing significantly in individuals >65 years 5
Critical Diagnostic Approach
Immediate resuscitation takes absolute priority before diagnostic efforts:
Establish IV access and correct fluid losses to restore blood pressure 4
Transfuse packed red blood cells to maintain hemoglobin >7 g/dL (threshold of 9 g/dL for massive bleeding or significant cardiovascular comorbidity) 4
Insert nasogastric tube to protect airway and decompress stomach in patients with hematemesis or massive bleeding 4
Esophagogastroduodenoscopy (EGD) is the gold standard first-line diagnostic and therapeutic intervention once hemodynamic stability is achieved, ideally within 24 hours of presentation. 4, 1, 3, 6
High-Risk Features Requiring Aggressive Management
The following endoscopic findings predict 50-80% risk of continued bleeding or death:
Non-bleeding visible vessel (50% rebleeding risk) 4
Ulcers ≥2 cm located at lesser curve or posterior duodenal bulb 7
Shock on presentation (pulse >100, systolic BP <100 mmHg) combined with active bleeding carries 80% risk of continued bleeding or death 4
When Endoscopy Fails
Catheter angiography with intent to embolize is indicated when:
EGD is unsuccessful in achieving initial hemostasis 4
Patient experiences recurrent bleeding after successful initial EGD and repeat EGD is unsuccessful or not recommended 4
Technical success rates reach 95%, with clinical success at 67% and 33% rebleeding rate 4
Common Pitfalls to Avoid
Nasogastric aspirate may be negative in 3-16% of patients with confirmed upper GI bleeding, so negative aspirate does not exclude upper GI source 1, 2
10-15% of patients with severe hematochezia (bright red rectal bleeding) actually have an upper GI source, requiring upper endoscopy even with lower GI presentation 8
Bleeding stops spontaneously in 75% of cases but carries 2-14% mortality risk despite spontaneous cessation, mandating aggressive evaluation even if bleeding appears to have stopped 1, 2