Hospital‐acquired gastrointestinal bleeding outside the critical care unit: Risk factors, role of acid suppression, and endoscopy findings

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Abstract
BACKGROUND: Risk factors for hospital‐acquired gastrointestinal bleeding in the intensive care unit are established, and acid‐suppressive prophylaxis has been advocated for certain subsets of critically ill patients. In contrast, risk factors and appropriate prevention strategies are not yet established for general medical patients. The objective of this study was to identify risk factors for nosocomial gastrointestinal bleeding (GIB) in non–critically ill medical patients, to evaluate the utility of prophylactic gastric acid suppression, and to characterize the endoscopic lesions. METHODS: This was a retrospective case–control study that took place at a U.S. tertiary care center. All patients admitted to the General Medicine ward for nongastrointestinal disorders who developed clinically relevant gastrointestinal bleeding during admission or within 4 weeks of discharge were considered cases. Clinically relevant bleeding was defined as any bleeding requiring esophagogastroduodenoscopy (EGD). Random controls were matched to cases by date of hospitalization in a 1:1 ratio. Clinical information was extracted by chart review. RESULTS: Of 17,707 patients admitted to the General Medicine ward over a 4‐year period, 73 (0.41%) met the case definition. The main risk factor for nosocomial GIB was treatment with full dose anticoagulants or clopidogrel (OR = 5.4; 2.6–11.7; P < .0001). Use of aspirin, nonsteroidal anti‐inflammatory medications, and glucocorticoids did not differ significantly between cases and controls. De novo acid‐suppressive prophylaxis was not protective (OR = 1.0; 95% CI: 0.4–2.4; P = 0.97). Endoscopic abnormalities were noted in 74% of patients; many cases had lesions unlikely to be prevented by acid blockade. CONCLUSIONS: Hospital‐acquired gastrointestinal bleeding is uncommon in non–critically ill patients. Anticoagulation appears to be the most important risk factor for nosocomial GIB. Routine use of acid suppressant medications for prophylaxis is unnecessary in most hospitalized patients. Journal of Hospital Medicine 2006;1:13–20. © 2006 Society of Hospital Medicine.