Occult vs. overt upper gastrointestinal bleeding – inverse relationship and the use of mucosal damaging and protective drugs

Summary Background While efforts have focused on the prevention of overt upper gastrointestinal bleeding ( UGIB ), little is known about occult GIB , which might also originate from sites not protected by acid inhibition. Aim To measure the incidence and outcomes of both overt and occult GIB over a 6‐year period (2007–2012), and to assess the use of NSAID s, anti‐thrombotic therapy ( ATT ), proton pump inhibitors ( PPI s), and iron therapy. Methods A sample of 300 patients (100 from each of three index years) with occult GIB was randomly selected and their outcomes were compared with those of patients with overt UGIB ( N  = 869). Results The incidence of overt UGIB fell from 140.1 per 100 000 population per annum in 2007 to 106.8 in 2010 and to 88.0 in 2012 ( P  < 0.001); while that of occult GIB rose from 243.1 to 263.6 and to 292.8 ( P  < 0.001) over the same period. The incidence of occult GIB was highly correlated with the number of prescriptions of PPI s per 1000 population (χ 2 trend = 11.80; P  < 0.001). In the overt UGIB group, the median haemoglobin level on presentation was lowest (10.3) in patients taking NSAID s/ ATT plus PPI s compared with those taking PPI s alone (11.5), NSAID s/ ATT alone (10.4) or none of these drugs (12.7 g/dL) ( P  < 0.001, Kruskal–Wallis). Conclusions An inverse trend seems to have formed in the incidence of overt vs. occult gastrointestinal bleeding in association with the wider use of PPI s and NSAID s. An alternative approach to acid inhibition is needed to prevent gastrointestinal bleeding .