Prevalence and prognostic significance of stigmata of bleeding in patients with gastric ulcers without overt hemorrhage on presentation

Background: Stigmata of bleeding are usually encountered by endoscopists when evaluating patients with overt upper gastrointestinal hemorrhage. We aimed to characterize the presence of stigmata of bleeding in a large cohort of patients with benign-appearing gastric ulcers without acute hemorrhage on presentation. Methods: 893 consecutive patients with a benign-appearing gastric ulcer diagnosed by endoscopy at our hospital from January 1992 to March 1997 were identified. Data were collected by reviewing endoscopy records, patient charts, and pathology reports. We compared the endoscopic findings in those patients without acute upper gastrointestinal hemorrhage to the findings in individuals who presented with bleeding. Acute upper gastrointestinal hemorrhage was defined as either hematemesis, coffee ground emesis, or melena associated with ≥2 g/dL decrease in hemoglobin. Cautery with or without epinephrine injection was performed in all patients found to have a visible vessel. Results: 331 of the 893 patients presented with upper gastrointestinal hemorrhage. Hemorrhage (N=331) No Hemorrhage (N=562) P Value Mean age, years 50.1 ± 1.0 49.2 ± 0.7 0.47 Male gender 201 (60.7%) 310 (55.2%) 0.11 Ulcer size, mm 19.4 ± 0.5 17.2 ± 0.4 0.0006 Stigmata of hemorrhage 201 (60.7%) 149 (26.5%) < 0.0001 Visible vessel 62 (18.7%) 31 (5.5%) < 0.0001 Adherent clot 79 (23.9%) 60 (10.7%) < 0.0001 Flat spot 82 (24.8%) 69 (12.3%) < 0.0001 Bleeding during follow-up 46 (13.9%) 29 (5.2%) < 0.0001 Among the 29 patients in the no hemorrhage group who had a subsequent bleed during follow-up, 23 individuals bled within 1 week of the initial endoscopy. Eighteen of these 23 (78.3%) had stigmata of bleeding noted during the initial endoscopy (visible vessel in 8, adherent clot in 8, and flat spot in 2). Conclusions: A surprisingly high prevalence of stigmata of bleeding (26.5%) were encountered in patients without overt hemorrhage on presentation. These stigmata appear to be clinically relevant, as 12.1% of the patients in the nonbleeding group with stigmata and 25.8% of those with treated visible vessels subsequently bled within 1 week. As expected, the presence of all types of stigmata were significantly higher in the patients who presented with acute gastrointestinal hemorrhage.