Upper gastrointestinal bleeding in the elderly

　　Common causes of upper gastrointestinal bleeding in the elderly include:
　　One, Common:Peptic ulcer, acute gastric mucosal lesion, gastric cancer, esophageal cancer, esophageal varices rupture, esophageal and cardia mucosal tear, etc.
　　Two, Other:① Esophagus: Reflux esophagitis, hiatal hernia, esophageal diverticulitis, esophageal ulcer, Barrett's esophagus, esophageal foreign body injury, chemical injury of esophagus, radiotherapy injury of esophagus; ② Stomach: Chronic gastritis, mucosal prolapse of stomach, acute gastric dilatation, postoperative changes of stomach after surgery (bile reflux anastomotic enteritis and residual gastritis, recurrent peptic ulcer, residual gastric cancer, etc.), smooth muscle tumor, smooth muscle sarcoma, lymphoma, neurofibroma, gastric polyps, etc.), changes in gastric blood vessels (gastric antrum vascular dilatation, arteriovenous malformation of gastroduodenal artery and vein, etc.); ③ Duodenum: Duodenitis, hookworm disease, duodenal diverticulitis; ④ Liver, gallbladder, pancreas: Biliary calculi, biliary ascaridiasis, gallbladder or bile duct cancer, liver cancer, pancreatic cancer, acute pancreatitis, etc.
　　Three, Pathogenesis
　　1. Factors causing bleeding and affecting hemostasis
　　(1) Mechanical injury: Such as injury to the esophagus by foreign bodies, abrasion of varicose veins by tablet preparations, and mucosal tears in the esophagus and cardia caused by severe vomiting, etc.
　　(2) The effect of gastric acid or other chemical factors: The latter includes acid and alkali corrosives, acidic and alkaline drugs, etc.
　　(3) Degeneration of mucosal protection and repair function: Aspirin, non-steroidal anti-inflammatory drugs, corticosteroids, infection, stress, etc., can destroy the protective and repair functions of the gastrointestinal mucosa.
　　(4) Vascular destruction: Inflammation, ulcers, malignant tumors, etc., can destroy arteries and veins, causing bleeding.
　　(5) Local or systemic hemostasis and coagulation disorders: The acidic environment of gastric juice is unfavorable for platelet aggregation and clot formation, anticoagulant drugs, systemic bleeding disorders, or coagulation disorders are prone to cause bleeding in the gastrointestinal tract and other parts of the body.
　　2, Pathophysiological changes after bleeding
　　(1) Decreased circulating blood volume: Elderly people often have arteriosclerosis in important organs such as the heart, brain, and kidneys. Even a slight decrease in circulating blood volume can cause significant ischemic manifestations in these important organs, even exacerbating the existing underlying diseases, causing functional abnormalities or failure of one to multiple important organs; large amount of bleeding is more likely to lead to peripheral circulatory failure and multi-organ failure.
　　(2) Absorption of blood protein decomposition products: Nitrogenous decomposition products absorbed through the intestines can cause azotemia; it was previously believed that the absorption of blood decomposition products could cause 'absorption fever', but now it is believed that the fever after gastrointestinal bleeding is related to dysfunction of the thermoregulatory center caused by a decrease in circulating blood volume.
　　(3) Compensation and repair of the body: ①Circulatory system: Heart rate increases, peripheral vascular resistance increases, to maintain blood perfusion of important organs; ②Endocrine system: Increased secretion of aldosterone and neurohypophyseal hormone, reducing water loss, to maintain blood volume; ③Hematopoietic system: Bone marrow hematopoiesis is active, reticulocytes increase, and the amount of red blood cells and hemoglobin gradually recovers.

　　The complications of elderly upper gastrointestinal bleeding mainly include local ulcers, rebleeding, perforation, shock, anemia, scar stenosis, and other severe conditions, which seriously harm the health of the elderly and affect the lifespan of the elderly. Therefore, once symptoms are found, treatment should be sought promptly.

　　The most common symptom of elderly upper gastrointestinal bleeding is bleeding, accompanied by other systemic manifestations.
　　First, the excretion of blood
　　1, Vomiting blood: ①Can be seen in esophageal bleeding, gastric bleeding with a large amount, duodenal bleeding, or jejunal bleeding after gastrojejunal anastomosis, with a large amount of bleeding, bleeding in these parts accompanied by vomiting, reflux, or obstruction. ②Color: Esophageal variceal bleeding often presents as dark red, if mixed with gastric juice and vomited out, it presents as coffee-colored; the vomit from gastric or duodenal bleeding is often coffee-colored, if the amount is large and not fully mixed with gastric juice, it may be dark red or bright red.
　　2, Black stools: ①Can be seen in upper gastrointestinal bleeding, jejuno-ileal or right half colon bleeding, slow excretion. ②Characteristics: The typical ones are black, shiny, sticky, resembling asphalt; if the amount of bleeding is small and mixed with stool, it can present as varying degrees of black-brown stools; when the stool is concentrated, it presents as asphalt-like, and when washed away with water, it presents as dark red. This condition can be seen in large amount of upper gastrointestinal bleeding, as well as lower gastrointestinal bleeding.
　　3, Dark red blood in stools: ①Commonly seen in colonic or jejuno-ileal bleeding; ②Also seen in large amount of upper gastrointestinal bleeding and quick excretion.
　　4, Fresh red blood in stools: ①Blood dripping or spurting after defecation, seen in anal and rectal bleeding; ②Small amount of fresh red blood in stools, or a small amount of fresh red blood attached to the surface of the stool, seen in anal and rectal or left half colon bleeding; ③Large amount of fresh red blood in stools, in addition to being seen in anal, rectal, left half colon bleeding, can also be seen in right half colon even small intestine bleeding, when the amount is large and excreted quickly.
　　5. Mixed feces: ① Jam-like feces, where feces and blood are mixed uniformly, often seen in right hemicolonic bleeding, such as amebic dysentery; ② Mucous or mucous pus feces, often seen in left hemicolonic bleeding, such as ulcerative colitis, bacterial dysentery, and others.
　　6. Positive fecal occult blood test: Slow and small amounts of bleeding may not change the appearance of feces, but only show a positive occult blood test.
　　7. Undischarged blood: Even with a large amount of bleeding, it may remain in the gastrointestinal tract for several hours without being excreted, which is prone to misdiagnosis at this time.
　　Two. Circulatory system manifestations
　　1. Circulatory system compensation: Symptoms such as tachycardia may occur. When blood has not been excreted, it is easy to misdiagnose it as the manifestation of pre-existing heart disease.
　　2. Insufficient blood supply to important organs: Elderly people often have underlying diseases such as cerebral arteriosclerosis and coronary heart disease, and bleeding can cause insufficient blood supply to important organs such as the heart, brain, and kidneys, leading to symptoms such as angina, arrhythmia, muffled heart sounds, dizziness, blacking out, syncope, drowsiness, confusion, decreased urine output, and are prone to misdiagnosis when blood has not been excreted.
　　3. Peripheral circulatory failure: Large-scale gastrointestinal bleeding can cause a rapid decrease in circulating blood volume, leading to peripheral circulatory failure, with symptoms such as dizziness, palpitations, thirst, blacking out, moist and cold skin, superficial venous collapse, fatigue, weakness, apathy, restlessness, dull reaction, tachycardia, and blood pressure drop, among others, which are manifestations of shock.
　　4. Cardiac changes due to anemia: Chronic recurrent gastrointestinal bleeding can cause severe and persistent anemia, leading to corresponding changes in the heart, such as cardiac enlargement.
　　Three. Blood picture
　　1. Anemia after bleeding: ① It can occur in acute massive bleeding or chronic recurrent bleeding; ② After acute bleeding, anemia usually appears after 3 to 4 hours; ③ It is mostly normocytic normochromic anemia, and macrocytic anemia may appear temporarily; ④ Within 24 hours after bleeding, reticulocytes can be elevated, reaching 5% to 15% after 4 to 7 days post-bleeding, and then gradually returning to normal.
　　2. Elevated white blood cell count: 2 to 5 hours after a large amount of bleeding, the white blood cell count may exceed 10×10⁹/L, it returns to normal 2 to 3 days after bleeding stops.
　　Four. Other
　　1. Azotemia: ① Intestinal origin, caused by the absorption of blood protein decomposition products, blood urea nitrogen levels rise several hours after bleeding, reaching a peak of 24 to 48 hours, usually not exceeding 6 to 7 mmol/L, and return to normal after 3 to 4 days; ② Pre-renal, caused by a temporary decrease in renal blood flow, can rapidly return to normal after correcting shock; ③ Renal, caused by renal failure, accompanied by oliguria or anuria, it is difficult to return to normal before correcting renal failure.
　　2. Fever: After a large amount of bleeding, most patients may experience low fever within 24 hours.
　　3. Depending on the cause and degree of bleeding, complications such as acute renal failure, infection, and hepatic encephalopathy may occur; bleeding can also exacerbate pre-existing lesions in the heart, brain, and kidneys, leading to corresponding clinical manifestations.
　　4. Manifestations of the primary disease.

　　The elderly should actively treat existing lesions, avoid alcohol, avoid the intake of foods and drugs that damage the mucosal lining of the digestive tract, and apply mucosal protective agents or antacids as needed. For patients with esophageal varices, avoid swallowing rough foods, and oral medications should be ground into powder. Propranolol plus nitrates can be used to reduce portal hypertension. Patients with hemorrhoids and colorectal polyps should pay attention to soft and smooth stools. In terms of details:

　　20. Treatment of the primary disease should be actively sought under the guidance of a doctor, such as peptic ulcer and liver cirrhosis.

　　19. Life should be regular. Meals should be timely and regular, avoid overeating and drinking, avoid alcohol and smoking, and avoid drinking strong tea and coffee to avoid damage to the mucosal lining of the digestive tract.

　　18. Pay attention to the use of drugs, try to use as few or no drugs that are irritating to the stomach, and if necessary, use drugs to maintain the integrity of the gastric mucosa.

　　17. Regular physical examinations should be scheduled to detect early lesions and receive timely treatment. When symptoms of anemia such as dizziness appear, it is best to go to the hospital for a check-up as soon as possible.

　　In addition to clinical symptoms, combining the results of the following tests can help diagnose upper gastrointestinal bleeding in the elderly.
　　Firstly, laboratory tests
　　12. 1. Changes in blood count: After a large amount of upper gastrointestinal bleeding, it takes a period of time, generally more than 3-4 hours, for tissue fluid to渗入血管内, diluting the blood, and hemoglobin and red blood cells decrease due to dilution, resulting in anemia. Acute bleeding is usually normocytic, normochromic anemia.
　　11. 2. Blood urea nitrogen, liver function, electrolytes, blood type, coagulation and anticoagulation mechanism, and other tests.
　　10. For severe bleeding, especially in patients with heart disease, central venous pressure measurement can be performed to assist in judging the fluid volume and infusion rate.
　　Secondly, other auxiliary examinations
　　8. Endoscopic examination: It is the most important method to understand the location and cause of gastrointestinal bleeding, with a diagnostic accuracy rate of 80% to 94%. Emergency endoscopic examination within 24 hours of bleeding is beneficial for detecting acute gastric mucosal lesions, superficial ulcer bleeding, and esophageal cardia mucosal tears. Biopsy can be performed under direct endoscopic vision to make a pathological diagnosis. Treatment can also be performed through the endoscope.
　　7. Barium enema X-ray: Including gastrointestinal barium meal, small intestine air-barium double contrast, and colon barium enema. It is suitable for acute bleeding that has stopped, or chronic bleeding, to understand the cause, and due to various reasons, endoscopic examination cannot be performed. It is prone to miss superficial mucosal lesions and difficult to diagnose vascular malformations.
　　6. Radionuclide imaging: After intravenous injection of 99mTc colloid, scanning is performed to detect evidence of tracer extravasation from the blood vessels. Non-invasive, but it must be performed during active bleeding.
　　5. Selective arteriography: Including selective celiac artery and mesenteric artery angiography. It must be performed during active bleeding, with a bleeding rate greater than 0.5ml/min.
　　4. Exploration surgery: When all other methods cannot clearly determine the cause and location of bleeding, and the situation is urgent, exploratory surgery can be performed.

　　The elderly have a decline in the function of the digestive system, so special attention should be paid to daily diet, and foods with strong刺激性 should be limited as much as possible.

　　I. Pay attention to diet

　　1. Abstain from alcohol. Regularly drinking strong alcohol can have a significant stimulating effect on the esophagus, and patients with upper gastrointestinal bleeding should abstain from drinking. Long-term alcoholism can also cause significant liver damage, affect the synthesis of coagulation factors, and easily induce upper gastrointestinal bleeding.

　　2. The harmful components in tobacco can have a significant stimulating effect on the gastrointestinal mucosa, easily causing inflammation of the gastrointestinal mucosa, leading to dysfunction of the pyloric and lower esophageal sphincter, resulting in bile and gastric contents reflux, and exacerbating the condition. It is very important for patients with a history of upper gastrointestinal bleeding to quit smoking.

　　3. Strong tea and strong coffee can strongly stimulate the secretion of gastric acid, which is not conducive to the regression of gastrointestinal inflammation and the healing of ulcers, so patients with a history of gastrointestinal bleeding should not drink strong tea or strong coffee.

　　4. Avoid spicy and刺激性 foods: Spicy, dry, fried foods, and seafood are more刺激性, which can damage the gastrointestinal mucosa and cause bleeding.

　　II. Appropriate diet

　　1. Regularly drinking milk can prevent upper gastrointestinal bleeding, protect the gastric mucosa, and simultaneously neutralize stomach acid, effectively preventing recurrent gastric bleeding.

　　2. Eat more fresh vegetables and fruits. For those with a tendency to bleed, eat more vitamin C and vitamin X-containing foods. Green leafy vegetables are rich in vitamin C, and citrus, dried fruits, tomatoes, and lemons also contain a high amount of vitamin C. Spinach, cabbage, cauliflower, rapeseed, and vegetable oils have a high content of vitamins. Eating more vitamin C-rich fresh fruits and vegetables can improve the permeability of capillaries, reduce the fragility of blood vessels, and is beneficial for hemostasis. It is also recommended to eat more foods with hemostatic effects, such as peanut skin, white fungus, bamboo shoots, chives, lily bulbs, lotus juice, and cuttlefish bone.

　　3. Honey is a traditional pure natural food with a fragrant smell. It is sweet and easy to digest and absorb by the human body. Honey can also make the burning sensation in the stomach disappear, has anti-inflammatory and promotes wound healing, enhances the function of the digestive system, and has a nourishing effect.

　　The treatment principle for elderly upper gastrointestinal bleeding is mainly to stop bleeding and treat the primary disease.
　　I. General management
　　1. Large amount of bleeding: Strengthen nursing care, fast, rest in bed, and maintain an unobstructed respiratory tract. Oxygen therapy, record urine output and blood loss, closely observe consciousness, body temperature, pulse, respiration, blood pressure, skin color, and venous filling, and if possible, perform electrocardiogram and blood pressure monitoring. If necessary, measure the central venous pressure.
　　2. Moderate or small amount of bleeding: Provide corresponding nursing, observation, and monitoring based on the amount of bleeding, age, and accompanying diseases; patients with hematemesis or variceal bleeding should fast, while other patients can generally eat a small amount of liquid or semi-liquid food.
　　II. Blood volume supplementation

　　The elderly have poor tolerance to ischemia, and blood volume supplementation should be more proactive, with blood transfusion indications relatively relaxed. After a large or moderate amount of bleeding, it is necessary to establish a venous access as soon as possible and to input an adequate amount of whole blood (fresh blood is preferable for patients with liver cirrhosis). It is best to adjust the fluid intake based on the central venous pressure to avoid pulmonary edema caused by excessive fluid intake. Patients with liver cirrhosis should be vigilant against rebleeding due to excessive blood transfusion and increased portal vein pressure.
　　Three, Hemostasis
　　1. Esophageal and gastric variceal bleeding:
　　① Somatostatin: Octreotide (Sandetide, somatostatin octapeptide) can be used, with an initial intravenous injection of 100μg, followed by an intravenous infusion of 25μg per hour, lasting for 72 hours. It can reduce visceral arterial blood flow, lower portal vein pressure, reduce the pressure and blood flow of esophageal and gastric varices, and achieve rapid hemostasis. The hemostatic rate is 70%-87%. Adverse reactions are rare.
　　② Neurohypophyseal hormone: It can also reduce portal vein pressure and achieve hemostasis, which has been the main treatment drug for this disease in the past. However, it has many adverse reactions, can induce angina pectoris, arrhythmias, etc., and is not suitable for the elderly. It can only be used cautiously when there are economic or other constraints and there is no alternative. It is contraindicated in patients with heart disease and hypertension. When used in combination with nitroglycerin, adverse reactions can be significantly reduced, and the recurrence rate of bleeding can be reduced.
　　③ Compression hemostasis with three-cavity balloon tube: This has been the main method of treatment for this disease in the past, with a short-term efficacy of about 80%, but a high incidence of rebleeding in a short period of time, and patients are relatively painful. It is necessary to be cautious of complications such as mucosal necrosis due to compression, balloon slipping and blocking the throat, aspiration pneumonia, etc. Now, it is often used in combination with octreotide (Sandetide) when satisfactory hemostasis is not achieved with octreotide.
　　④ Endoscopic treatment: Endoscopic ligation, a simple method with good efficacy and few complications; injection of sclerosing agents into varicose veins under endoscopy has an overall effective hemostasis rate of 85.4%, but can cause complications such as esophageal ulcers, pleural effusion, mediastinitis, etc. It is only suitable for high-risk patients who are not suitable for surgery and have failed other methods.
　　⑤ Surgical treatment: Suitable for those who have poor response to medical treatment and are allowed to undergo surgery.
　　⑥ Other: Hemostatic agents such as thrombin (Lishizhi) and antisecretory drugs such as omeprazole (Losec) can be helpful in accelerating hemostasis and preventing rebleeding.
　　2. Other upper gastrointestinal bleeding:
　　① Antisecretory drugs: Inhibit the secretion of gastric acid, inhibit the self-digestion of mucosal tissue by gastric acid and pepsin; reduce the local pH value, which is conducive to the aggregation of platelets and the formation of blood clots at the bleeding site. It is the most basic treatment method for most upper gastrointestinal bleeding, and a considerable number of patients can stop bleeding after antacid treatment. Proton pump inhibitors such as omeprazole (Losec) can be used, 40mg intravenous injection, 1-2 times a day, or 40mg intravenous infusion, and after bleeding control, it can be changed to oral administration. It has strong acid-suppressing effect, few adverse reactions, and a hemostatic rate of over 90% for peptic ulcers. H2 receptor antagonists such as cimetidine, ranitidine, and famotidine can also be used, initially administered intravenously and then changed to oral administration after the condition improves.
　　② Vasopressors: 6-8mg of norepinephrine, mixed with 30-100ml of normal saline for oral administration, 1 time every 6-8 hours, with rapid onset. Absorption is low, metabolism is fast, so it does not affect heart rate or blood pressure. However, be cautious of ischemic damage to the mucosa of the digestive tract. Methods such as lavage with ice water, oral administration of Mension's solution, or spraying under endoscopy have similar effects.
　　③ Somatostatin: Oxtreotide (Sandet) 100μg can be administered subcutaneously, once every 8 hours. It can also be administered intravenously or intravenously in case of necessity. It has multiple effects such as inhibiting gastric acid, promoting gastrin and pepsin, reducing visceral blood flow, and protecting the gastric mucosa, with a hemostasis rate of 87% to 100% for peptic ulcers and acute gastric mucosal lesions. Considering the cost factor, it can be used when bleeding is severe and other internal medicine methods are ineffective.
　　④ Hemostatic agents: Locally, thrombin, Yunnan Baiyao, Atractylodes macrocephala preparations, and Polygonum cuspidatum preparations can be used. Systemically (intravenous, intramuscular) can be used with batroxobin (Lizhi). Frozen thrombin complex is used for those with coagulation mechanism disorders. The efficacy of other hemostatic agents such as phenolsulfonate (hemostatic agent) is not certain.
　　⑤ Endoscopic hemostasis: There are methods such as spraying hemostatic agents, local drug injection, high-frequency electrocoagulation hemostasis, laser hemostasis, and microwave hemostasis. In elderly upper gastrointestinal bleeding, due to the presence of vascular sclerosis, bleeding may be persistent or recurrent. At this time, high-frequency electrocoagulation or laser can be considered, but indications should be strictly controlled and complications such as arterial hemorrhage and perforation should be prevented.
　　⑥ Surgical treatment: Surgery can be considered in cases with perforation, pyloric obstruction, malignant tumors, or when internal medicine methods cannot stop bleeding. Since the development of internal medicine is fast and the choice is wide, and there is a risk of postoperative residual gastric cancer and other lesions, surgery should be decided with caution.
　　4. Other treatments
　　1. Management of secondary lesions: Acute renal failure, treated as acute renal failure caused by shock. Appropriate treatment is given for infections, hepatic encephalopathy, etc. For anemia after hemorrhage, iron supplements and appropriate increase in protein nutrition can be supplemented, and the recovery is generally fast after bleeding stops. Polysaccharide iron complex (Lifengneng) is a non-ionic iron preparation in chelated state, with small dosage, complete absorption, and few adverse reactions; oral administration of 150mg, once a day. Severe anemia in the elderly may worsen existing heart, brain, and kidney damage, and red blood cell transfusion should be considered when necessary.
　　2. Treatment of primary lesions
　　3. Treatment of associated lesions: The elderly often have underlying diseases of important organs such as the heart. After gastrointestinal bleeding, these associated lesions may be interrelated with hemorrhagic damage and affect the evolution of the disease. Therefore, in the treatment and rescue of gastrointestinal bleeding, attention should be paid to the treatment of associated lesions such as heart disease, which often becomes the key to the success of rescue.