Management of Massive Upper Gastrointestinal Bleeding in Adults ≥ 60 Years

Epidemiology & Age‑Related Risk Factors

Age > 60 years is an independent predictor of mortality in acute upper GI bleeding, with mortality rates rising sharply compared with patients < 40 years. [3][4]
Presence of comorbid conditions such as cardiac disease, renal insufficiency, liver disease, or disseminated malignancy markedly worsens prognosis in this age group. [3][4]

Immediate establishment of large‑bore intravenous access and rapid fluid replacement are essential to restore hemodynamic stability before endoscopic evaluation. [3][4]
Packed red blood cell transfusion should be administered to keep hemoglobin ≥ 7 g/dL (threshold ≥ 9 g/dL for massive bleeding or significant cardiovascular comorbidity). [5][6]
In patients with hematemesis or massive bleeding, insertion of a nasogastric tube is recommended to protect the airway and decompress the stomach. [5][6]

Esophagogastroduodenoscopy (EGD) is the gold‑standard first‑line diagnostic and therapeutic modality for upper GI bleeding; it should be performed once the patient is hemodynamically stable, ideally within 24 hours of presentation. 7

Active arterial spurting or oozing from a peptic ulcer predicts a 50–80 % risk of continued bleeding or death. [3][4]
A non‑bleeding visible vessel on the ulcer base carries approximately a 50 % risk of re‑bleeding. [3][4]
Presentation with shock (heart rate > 100 bpm and systolic blood pressure < 100 mmHg) together with active bleeding confers an ≈ 80 % risk of ongoing hemorrhage or mortality. [3][4]

Catheter‑directed angiography with embolization is indicated if initial EGD does not achieve hemostasis. 7
Angiography is also appropriate for recurrent bleeding after successful initial endoscopic therapy when repeat EGD is unsuccessful or not advisable. 7
Technical success of angiographic embolization is reported at ≈ 95 %; clinical success (cessation of bleeding) occurs in ≈ 67 % of cases, with a re‑bleeding rate of ≈ 33 %. 7