Upper Gastrointestinal Bleeding in the Medical Intensive Care Unit (MICU) Doha, Qatar: A one-year survey

**Kamha A.,*Al Kaabi S., and *Sattar H.A.
Departments of *Medicine and **Medical Intensive Care
Hamad Medical Corporation, Doha, Qatar

Abstract:

Upper gastrointestinal bleeding is a common problem and is an important cause of morbidity and mortality. Between June 1999 to May 2000 eight hundred and sixty patients were admitted to the Medical Intensive Care Unit, Hamad Medical Corporation, 102 of whom (11.8%) were admitted with a diagnosis of upper gastrointestinal bleeding. The most common nationality was Qatari (42.2%) and the most common age group was between 50-60years old (28.4%). The most frequent cause of bleeding was peptic ulcer disease (50 patients) followed by variceal bleeding. Our results are compatible with other reports.

Key words: Upper gastrointestinal bleeding, intensive care, Qatar.

Introduction:

The MICU in Hamad Medical Corporation is a 15-bed unit for adult medical patients and is separate from similar units for Coronary and Surgical care. It admits about one thousand cases annually from all medical sub-specialties (pulmonary, neurological, etc).

Patients admitted to the Medical Intensive Care Unit (MICU) are the more sick who need close observation and proper assessment.

Although many of our admissions (20%) are patients with varying degrees of severe renal failure, upper gastrointestinal (GI) bleeding is a common and serious problem and is also a frequent cause of admission to MICU (10-15% of cases in our critical area). Management is both complicated and demanding⁽¹⁾. Such patients usually have hemodynamic instability, e.g., shock, postural hypotension, drop in hematocrit of at least 6% or requirement of more than two units of packed red blood cells. Most will have clear evidence of upper GI bleeding such as vomiting of fresh blood or multiple episodes of melaena on the day of presentation, severe anaemia (haemoglobin < 8 gm/dl)⁽²⁾, or are patients with serious concomitant illness, severe chronic liver disease or are on anticoagulation therapy. These patients are observed with blood pressure monitoring/EEG monitoring, pulse oximetry and adequate resuscitation measures for stabilization.

Such a retrospective study of cases admitted to the Medical Intensive Care unit (MICU) with upper GI bleeding has not been reported previously from our hospital.

Methods:

We reviewed all files of those cases admitted to MICU with a diagnosis of upper GI bleeding over one year from June 1999 until the end of May 2000. One hundred and two cases (11.8% of total admissions) were admitted with upper GI bleeding out of 860 patients admitted to MICU. Age, sex, nationality, procedures done and status at discharge were noted.

Evaluation and Definitions:

Outcome was evaluated in respect of:

a) Mortality during admission

b) Emergency surgery performed during active bleeding

c) Spontaneous resolution of bleeding by conservative treatment.

Massive upper GI bleeding was defined as loss of more than 1000 ml of blood evaluated by postural drop in blood pressure 20 mm/Hg systolic and 10 mm/Hg diastolic or more and pulse rate above 100 per minute and decrease in haemoglobin level to less than 10 gm/dl with or without fainting attack⁽²⁾. Upper endoscopy was our diagnostic modality of choice but other methods were used to evaluate a small number of patients with upper gastrointestinal bleeding (tagged RBCs, barium studies, angiographies and surgical exploration).

Results:

Upper GI bleeding was more common in males (78 cases; 76.4%) than females (24 cases; 23.6%) with a male to female ratio of 3.25:1 (Table 1).

Table 1:



Eighty-seven of these cases (85.3%) were admitted directly from the Accident and Emergency Department. Fifteen patients (14.7%) were admitted initially to the medical wards then were re-evaluated and transferred to MICU. Qatari nationality was the most common nationality to be admitted to MICU with upper GI bleeding, 43 cases out of a total of 102 (42.2%); Egyptian nationality was the next most common, 12 cases (11.8%). (Table 2).

Table 2:

There were also 3 Sudanese, 3 Jordanians, 2 Nepali, 2 Yemenis, and 2 Philippine patients and one patient from each of U.K., Somalia, Libya and Syria.

The most common age was 50 - 60 years (29 cases; 28.4%) and the mean age was 42 years (Table 3). Bleeding from gastric or duodenal ulcers was the common cause of bleeding in Qatari patients, while variceal bleeding was the common cause of bleeding in Egyptian patients.

There were also two cases aged 10-20 years, six cases 21-30 years, 15 cases 31-40 years and 12 cases above 70 years old. Ten patients died (9.8% mortality rate). Eight of the ten were known to have advanced chronic liver disease, one patient was very old (above 110 years of age); the family refused endoscopy and asked only for supportive care. The tenth patient was known to have a gastric ulcer with a second attack of massive

Table 3:



 upper GI bleeding in the same week; upper endoscopy was done and endoscopic treatment was tried but failed to control the bleeding. He died on the way to the operating theatre.

Upper endoscopy was done on 96 patients (94.1%); 50 patients (49%) had peptic ulcer disease, 27 gastric ulcers, 23 duodenal ulcers; 36 had variceal bleeding (35.3%) (Table 4). Upper endoscopy was not done in six patients; two had obvious lower gastrointestinal bleeding and sigmoidoscopy and colonoscopy were advised, and the other four patients were sufficiently stable to be transferred to a medical floor for regular follow-up. Surgical opinion was requested in 16 cases (nine cases with variceal bleeding and seven cases with bleeding from gastric or duodenal ulcers), 11 cases were operated upon and conservative and supportive care was recommended for five cases.

Table 4: Results of upper endoscopy done in MICU in Hamad Medical Corporation

Discussion:

The State of Qatar is an Arabian Gulf Emirate with a population of about 750,000 of whom two-thirds are temporary immigrant workers, mostly male, of various nationalities.

Upper gastrointestinal bleeding is a common reason for admission to the MICU of Hamad General Hospital, the only referral hospital in the country. Although Qatar has this multinational community, most admissions (42.2%) to the MICU were Qatari.

The surgical team on-call and the gastrointestinal team were involved in all cases of severe upper GI bleeding⁽¹⁾.

Upper endoscopy is our diagnostic modality of choice for acute upper GI bleeding^{(3, 4)} as it permits the early detection and prognostic evaluation of a source of hemorrhage and serves as a baseline for decision making with regard to subsequent therapeutic measures⁽⁵⁾. The most common cause of upper GI bleeding was peptic ulcer disease (PUD) followed by gastro-oesophageal variceal bleeding. This is compatible with international studies of upper GI bleeding (Table 5).

From the fifty cases with upper gastrointestinal bleeding due to peptic ulcer disease a strong positive history was obtained of the use of non-steroidal anti-inflammatory drugs in eighteen patients (36%); the NSAIDs were considered the causative agent of upper gastrointestinal bleeding in this group (Table 6). The high incidence of upper gastrointestinal bleeding induced by NSAIDs may be attributed to the common use of NSAIDs in our area with or without consulting the primary care physicians

Active treatment of PUD used to be in the form of upper endoscopy in the first twenty-four hours after admission and intravenous H2 blockers such as rhanitidine. After stabilization of the patient, intravenous rhanitidine was discontinued and treatment was continued with oral omepazol. Somatostatin, or its analogue octreotide, was used when available for treatment of variceal bleeding as adjunctive therapy with endoscopy; also it was used when endoscopy was unsuccessful or contraindicated ⁽¹²⁾.

Variceal hemorrhage was associated with more substantial morbidity and mortality than other causes of upper GI bleeding as well as high hospital costs^(13,14,15). Emergency sclerotherapy and banding ligation were used for treatment of active variceal bleeding^(16,17). Vasopressin plus nitroglycerin infusion were also used to help control actively bleeding oesophageal varices. Improved intensive care measures and endoscopic therapy for this group of patients with upper GI bleeding may account for the significant decline in mortality rate during the past 20 years ^(18,19).

Table 6: Upper GI bleeding induced by NSAIDs.



Table 5: Literature survey of causes of upper gastrointestinal bleeding

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