|Year : 2016 | Volume
| Issue : 2 | Page : 29-32
Etiology of upper gastrointestinal bleeding in the University of Benin Teaching Hospital, South-Southern Nigeria
Rose Ashinedu Ugiagbe, Casmir E Omuemu
Department of Medicine, Gastroenterology Unit, University of Benin Teaching Hospital, Benin, Edo State, Nigeria
|Date of Web Publication||12-Jun-2017|
Rose Ashinedu Ugiagbe
Department of Medicine, Gastroenterology Unit, University of Benin Teaching Hospital, Benin, Edo State
Source of Support: None, Conflict of Interest: None
Background: Upper gastrointestinal (GI) bleeding is a medical emergency that remains a common cause of morbidity and mortality worldwide. The aim of this study was to determine the common causes of upper GI bleeding in the University of Benin Teaching Hospital, South-Southern Nigeria. Methods: Records of all patients referred with upper GI bleeding to the endoscopy unit of the University of Benin Teaching Hospital from February 2006 to January 2013 were reviewed. Relevant data and findings at diagnostic upper GI endoscopy were retrieved from the endoscopy register. Data obtained were analyzed using Statistical Package for Social Sciences version 15.0. Results: A total of 1084 patients had upper GI endoscopy during the study, of those 311 (28.7%) had upper GI bleeding. The mean age of patients with upper GI bleeding was 51.48 ± 17.5. Range was 14–90 years and the male: female ratio was 2.04:1. The most common cause of upper GI bleeding was peptic ulcer disease (PUD), found in 102 (32.8%) cases, followed by gastritis in 88 (28.3%) cases. Esophageal varices accounted for 47 (15.1%) cases whereas duodenitis was found in 16 (5.1%) cases. Carcinoma of the stomach occurred in 13 (4.2%) cases while 12 (3.9%) patients had esophagitis. Gastroesophageal reflux disease accounted for 11 (3.5%) cases whereas esophageal ulcers occurred in 3 (1.0%) cases. Carcinoma of the esophagus and esophageal candidiasis each constituted 2 (0.6%) cases. The cause of bleeding was not found in 15 (4.8%) patients. Conclusion: PUD is the most common cause of upper GI bleeding in patients undergoing endoscopy in the University of Benin Teaching Hospital, South-Southern Nigeria.
Keywords: Etiology, South-Southern Nigeria, upper gastrointestinal bleeding
|How to cite this article:|
Ugiagbe RA, Omuemu CE. Etiology of upper gastrointestinal bleeding in the University of Benin Teaching Hospital, South-Southern Nigeria. Niger J Surg Sci 2016;26:29-32
|How to cite this URL:|
Ugiagbe RA, Omuemu CE. Etiology of upper gastrointestinal bleeding in the University of Benin Teaching Hospital, South-Southern Nigeria. Niger J Surg Sci [serial online] 2016 [cited 2018 Jul 19];26:29-32. Available from: http://www.njssjournal.org/text.asp?2016/26/2/29/207753
| Introduction|| |
Upper gastrointestinal (GI) bleeding refers to blood loss within the intraluminal GI tract proximal to the ligament of Treitz. Upper GI bleeding is a medical emergency that remains a common cause of morbidity and mortality worldwide., The incidence of upper GI bleeding increases with age and is twice as common in males as in females., Bleeding from the upper GI tract is approximately four times as common as bleeding from the lower GI tract.
The etiology of upper GI bleeding varies significantly with geographic regions depending on the demographics and socioeconomic characteristics. Causes of upper GI bleeding could be variceal such as esophageal and gastric varices and nonvariceal such as peptic ulcer disease (PUD), erosive gastroduodenitis, reflux esophagitis, tumors, vascular ectasia to mention a few. Identification of the cause of bleeding is important in effective management of the patient. Panendoscopy of the upper GI tract is indeed the diagnostic modality of choice for acute upper GI bleeding with more sophisticated investigation such as angiography and computed tomography being rarely indicated where endoscopy is inconclusive.
Previous studies in the northern part of Nigeria reported esophageal varices as the most common cause of upper GI bleeding,, while studies from Ekiti, Nigeria, and Ilorin, Nigeria, reported gastric erosions and multiple sources of bleeding, respectively, as their most common endoscopic findings. In developed countries, studies reported peptic ulcer as the most common cause of upper GI bleeding.,,
The aim of this study was to determine the common causes of upper GI bleeding in the University of Benin Teaching Hospital with a view to bridging the existing knowledge gap on this subject and as a basis for its effective management.
| Methods|| |
Study design and setting
This was a descriptive, retrospective study of patients who underwent upper GI endoscopy for upper GI bleeding at the endoscopy unit of the University of Benin Teaching Hospital over a 7-year period from February 2006 to January 2013. The University of Benin Teaching Hospital is located in the south-south region of Nigeria and is one of the hospitals that cater to the health needs of patients in this geographical zone with a population of over 10 million people.
Subjects of this study included all upper GI bleeding patients who had upper GI endoscopy during the study. Patients who had other indications for endoscopy other than upper GI bleeding and those with therapeutic indications were excluded from the study. The biodata as well as the findings from the procedure were obtained from the endoscopy register of the endoscopy unit of the University of Benin Teaching Hospital.
For the procedure, patients fasted overnight, informed consent was obtained, and counseling was done. The pharynx was sprayed with 2% xylocaine and occasional premedication with 20–40 mg of intravenous hyoscine butyl bromide and 5–10 mg of diazepam in very anxious patients. A systematic examination of the esophagus, stomach, first and second parts of the duodenum was carried out using a gastroscope (Pentax video gastroscope - PENTAX EG-2931K, and Olympus Fiber gastroscope).
The data obtained were analyzed using the Statistical Package for Social Sciences version 15.0 (SPSS. V.15.0, incorporated, Chicago, Illinois, USA). The mean ± standard deviation (SD), median, and ranges were calculated for continuous variables whereas proportions and frequency tables were used to summarize categorical variables.
Ethical approval to conduct the study was obtained from the Hospital's Ethical Committee.
| Results|| |
A total of 1084 patients had upper GI endoscopy during the study, of those 311 (28.7%) had upper GI bleeding. Two hundred and nine (67.2%) patients were male while 102 (32.8%) were female, with a male to female ratio of 2.04:1. Their ages ranged from age 14 to 90 years, with a mean ± SD and median age of 51.48 ± 17.5 and 52 years, respectively. The modal age group was 50–59 years (20.3%). Most of the patients were below 60 years of age as shown in [Table 1].
[Table 2] shows that the most common cause of bleeding was PUD, i.e., gastric ulcers 62 (19.9%) and duodenal ulcers 40 (12.9%), giving a total of 102 (32.8%) cases. This was followed by gastritis in 88 (28.3%) cases. Esophageal varices were found in 47 (15.1%) cases whereas duodenitis accounted for 16 (5.1%) cases. Carcinoma of the stomach occurred in 13 (4.2%) cases while esophagitis was seen in 12 (3.9%) cases. Gastroesophageal reflux disease (GERD) accounted for 11 (3.5%) cases whereas esophageal ulcers occurred in 3 (1.0%) cases. Carcinoma of the esophagus and esophageal candidiasis accounted for 2 (0.6%) cases each. The cause of bleeding was not found in 15 (4.8%) patients.
|Table 2: Endoscopic findings in patients with upper gastrointestinal bleeding|
Click here to view
| Discussion|| |
Upper GI bleeding is a common cause of morbidity and mortality worldwide, and identification of the cause of bleeding is important in management and prognostication of the patients. This study showed that PUD was the most common cause of upper GI bleeding in the University of Benin Teaching Hospital accounting for 32.8% of cases, about one-third of all cases. This is similar to the findings in the United States, Europe, and Kenya in Africa ,,,,,,, but contrast with the reports from northern part of Nigeria,, Egypt,, and Tanzania, where esophageal varices were reported as their most prevalent cause of upper GI bleeding. The difference in the etiology of upper GI bleeding between the north and south may be partly explained by the high prevalence of chronic liver disease in the northern part of Nigeria.,, Chronic liver disease reportedly is the most common cause of portal hypertension and this in turn predisposes to varices.
The majority of cases of peptic ulcer bleeding are self-limiting with an uneventful recovery requiring only medical treatment. However, a subset of patients continues to bleed or have recurrent bleeding which is associated with a poor prognosis. Some of these patients would benefit from endoscopic therapies such as injection therapy, thermal coagulation, hemoclips, and argon plasma coagulation.,, Interventional radiology or surgery is reserved for those who do not respond to endoscopic therapy.
There is a definite role of nonsteroidal anti-inflammatory drug (NSAID) use as well as alcohol ingestion in the etiology of bleeding PUD, especially bleeding gastric ulcers which occurred quite frequently in this study. Helicobacter pylori infection has also been implicated in the etiology of duodenal ulcers. Other predisposing factors to bleeding PUD include use of steroids or anticoagulants and comorbid conditions such as cardiovascular and cerebrovascular disease. However, the contribution of each of these is beyond the scope of this retrospective study.
Gastritis occurred in 28.3% of the patients, being the second most common cause of upper GI bleeding in this study. This compares with the reports from Northeastern Nigeria, Europe, South America, and India,,,, where erosive mucosal disease ranked second in their studies, but contrast with reports from Ekiti, Nigeria, where gastritis ranked first and PUD second. Just as for bleeding PUD, risk factors such as NSAID use and alcohol ingestion have also been implicated in erosive mucosal disease.
The third most common cause of bleeding is esophageal varices accounting for 15.1% of cases. This is similar to a previous report from Ekiti, Nigeria, where varices ranked third in their review, but contrast sharply with reports from northern part of Nigeria, Egypt, and Tanzania, where esophageal varices were their most common finding.,,,, Esophageal varices develop as a result of systemic or segmental portal hypertension, the most common cause of portal hypertension being chronic liver disease. Treatment options for esophageal varices are band ligation or injection sclerotherapy.,,
Rare causes of upper GI bleeding in this study include duodenitis, carcinoma of the stomach, esophagitis, GERD, esophageal ulcers, carcinoma of the esophagus, and esophageal candidiasis.
In this study, the cause of bleeding was not found in 4.8% of cases, which implies that the cause of bleeding was detected in 95.2% of cases. This finding is similar to the previous reports from other regions , and agrees with the report that upper GI endoscopy is an effective initial diagnostic modality in localizing the site and cause of bleeding in 85%–90% of patients. The quick healing of mucosal lesion as well as the time interval between the bleeding episode and endoscopic procedure is known to influence the likelihood of finding a cause at endoscopy. This underscores the need for well-trained endoscopy teams and facilities for emergency endoscopy. These patients for whom the cause of bleeding was not found had no endoscopic evidence of upper GI bleeding at endoscopy and fortunately did not require further investigations.
The mean age of our patients was 51.5 years, which is lower than reports from the Western world , but slightly higher than previous reports from Nigeria  and Tanzania. These differences may reflect inherent differences in the studied population. This study showed a two-fold increase in the number of males with upper GI bleeding compared to females as has been previously reported.,, No factors that could account for this were identified in this study.
Treatment and outcome are beyond the scope of this study. This study, nonetheless, will form the basis for a prospective study in the future centered on the management and outcome of upper GI bleeding in the hospital. The treatment modalities for upper GI bleeding include conservative, endoscopic, and surgical management. Majority of our patients were managed conservatively with fluid replacements, blood transfusions, parenteral proton pump inhibitors, or octreotide as required. In addition, some had endoscopic management of bleeding PUD with injection therapy or banding of esophageal varices while a few had surgery.
| Conclusion|| |
This study showed that PUD is the most common cause of upper GI bleeding in the University of Benin Teaching Hospital, South-Southern Nigeria. The provision of therapeutic endoscopy facilities and drugs for upper GI bleeding should be tailored toward the common causes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jaka H, Koy M, Liwa A, Kobangila R, Mivambo M, Scheppach, et al
. A fibreoptic endoscopic study of upper gastrointestinal bleeding at Bugando Medical Centre in North Western Tanzania: A retrospective review of 240 cases. BMC Res Notes 2012;5:200.
Sarin N, Monga N, Adams PC. Time to endoscopy and outcomes in upper gastrointestinal bleeding. Can J Gastroenterol 2009;23:489-93.
Elghuel A. The characteristics of adults with upper gastrointestinal bleeding admitted to Tripoli Medical Center: A retrospective case-series analysis. Libyan J Med 2011;6:6283.
Jutabha R, Jensen DM. Management of upper gastrointestinal bleeding in the patient with chronic liver disease. Med Clin North Am 1996;80:1035-68.
Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: A population-based study. Am J Gastroenterol 1995;90:206-10.
Palmer K. Management of haematemesis and melaena. Postgrad Med J 2004;80:399-404.
Theocharis GJ, Thomopoulos KC, Sakellaropoulos G, Katsakoulis E, Nikolopoulou V. Changing trends in the epidemiology and clinical outcome of acute upper gastrointestinal bleeding in a defined geographical area in Greece. J Clin Gastroenterol 2008;42:128-33.
Tijjani BM, Borodo MM, Samaila AA. Endoscopic findings in patients with upper gastrointestinal bleeding in Kano, North-Western Nigeria. Niger Hosp Pract 2009;4:43-5.
Malu AO, Wali SS, Kazmi R, Macauley D, Fakunle YM. Upper gastrointestinal endoscopy in Zaria, Northern Nigeria. West Afr J Med 1990;9:279-84.
Mustapha S, Ajayi N, Shehu A. Aetiology of upper gastrointestinal bleeding in North-Eastern Nigeria: A retrospective endoscopic study. Internet J Third World Med 2009;8:2.
Oladiniyi AA, Temi AP, Adekunle AE, Abidemi SO, Olatayo AA, Abayomi AM. Aetiology and Management Outcome of Upper Gastrointestinal Bleeding in Adult patients Presenting at Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria. Greener Journal of Medical Sciences 2013;3:93-7.
Olokoba AB, Olokoba LB, Jimoh AA. Upper gastrointestinal tract bleeding in Ilorin, Nigeria – A report of 30 cases. Niger J Clin Pract 2009;12:240-4.
Rockall TA, Logan RF, Devlin HB, Northfield TC. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering committee and members of the national audit of acute upper gastrointestinal haemorrhage. BMJ 1995;311:222-6.
Vreeburg EM, Snel P, de Bruijne JW, Bartelsman JF, Rauws EA, Tytgat GN. Acute upper gastrointestinal bleeding in the Amsterdam area: Incidence, diagnosis, and clinical outcome. Am J Gastroenterol 1997;92:236-43.
Zaltman C, Souza HS, Castro ME, Sobral Mde F, Dias PC, Lemos V Jr. Upper gastrointestinal bleeding in a Brazilian hospital: A retrospective study of endoscopic records. Arq Gastroenterol 2002;39:74-80.
Silverstein FE, Gilbert DA, Tedesco FJ, Buenger NK, Persing J. The national ASGE survey on upper gastrointestinal bleeding. II. Clinical prognostic factors. Gastrointest Endosc 1981;27:80-93.
Gostout CJ, Wang KK, Ahlquist DA, Clain JE, Hughes RW, Larson MV, et al.
Acute gastrointestinal bleeding. Experience of a specialized management team. J Clin Gastroenterol 1992;14:260-7.
Zimmerman J, Meroz Y, Siguencia J, Tsvang E, Arnon R. Upper gastrointestinal hemorrhage. Comparison of the causes and prognosis in primary and secondary bleeders. Scand J Gastroenterol 1994;29:795-8.
Enestvedt BK, Gralnek IM, Mattek N, Lieberman DA, Eisen G. An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium. Gastrointest Endosc 2008;67:422-9.
Hansen DP, Daly DS. A fibreendoscopic study of acute upper gastrointestinal hemorrhage in Nairobi, Kenya. Am J Trop Med Hyg 1978;27:197-200.
Abdulkareem YK, Fuad HI, Maher A, Basil AI. Acute upper gastrointestinal bleeding in Kuwait. Kuwait Med J 2001;33:144-7.
Kanha A, AI Kaabi S, Saltar HA. Upper gastrointestinal bleeding in the Medical Intensive Care Unit Doha Qatar. A one year survey. Qatar Med J 2003;12:22-7.
Stiegmann GV, Sun JH, Hammond WS. Results of experimental endoscopic esophageal varix ligation. Am Surg 1988;54:105-8.
Lodenzo H, Okoth FA. Injection sclerotherapy in patients with partial hypertension seen at the centre for clinical research, Kenya Medical Research Institute. Afr J Health Sci 2007;14:216-8.
Jiranek GC, Kozarek RA. A cost-effective approach to the patient with peptic ulcer bleeding. Surg Clin North Am 1996;76:83-103.
Chan FK, To KF, Wu JC, Yung MY, Leung WK, Kwok T, et al.
Eradication of Helicobacter pylori
and risk of peptic ulcers in patients starting long-term treatment with non-steroidal anti-inflammatory drugs: A randomised trial. Lancet 2002;359:9-13.
Pruthi HS, Sharma SK, Singh B, Anand AC. Aetiology of upper gastrointestinal bleeding: An endoscopic study. Med J Armed Forces India 2000;56:188-91.
Garcia-Tsao G, Groszmann RJ, Fisher RL, Conn HO, Atterbury CE, Glickman M. Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology 1985;5:419-24.
Suba M, Ayana SM, Mtabho CM, Kibiki GS. The aetiology, management and clinical outcome of upper gastrointestinal bleeding among patients admitted at the Kilimanjaro Christian Medical Centre in Moshi, Tanzania. Tanzan J Health Res 2010;12:302-5.
Arora NK, Ganguly S, Mathur P, Ahuja A, Patwari A. Upper gastrointestinal bleeding: Etiology and management. Indian J Pediatr 2002;69:155-68.
[Table 1], [Table 2]