Trends in Characteristics, Management, and Outcomes of Patients Presenting With Gastrointestinal Bleeding to Emergency Departments in the United States From 2006 to 2019

Neil S. Zheng; Cynthia Tsay; Loren Laine; Dennis L. Shung


Aliment Pharmacol Ther. 2022;56(11):1543-1555. 

In This Article

Abstract and Introduction


Background: Recent epidemiologic studies of trends in gastrointestinal bleeding (GIB) provided results through 2014 or earlier and assessed only hospitalised patients, excluding patients presenting to emergency departments (EDs) who are not hospitalised.

Aims: To provide the first U.S. nationwide epidemiological evaluation of all patients presenting to EDs with GIB

Methods: We used the Nationwide Emergency Department Sample for 2006–2019 to calculate yearly projected incidence of patients presenting to EDs with primary diagnoses of GIB, categorised by location and aetiology. Outcomes were assessed with multivariable analyses.

Results: The age/sex-adjusted incidence for GIB increased from 378.4 to 397.5/100,000 population from 2006 to 2019. Upper gastrointestinal bleeding (UGIB) incidence decreased from 2006 to 2014 (112.3–94.4/100,000) before increasing to 116.2/100,000 by 2019. Lower gastrointestinal bleeding (LGIB) incidence increased from 2006 to 2015 (146.0 to 161.0/100,000) before declining to 150.2/100,000 by 2019. The proportion of cases with one or more comorbidities increased from 27.4% to 35.9% from 2006 to 2019. Multivariable analyses comparing 2019 to 2006 showed increases in ED discharges (odds ratio [OR] = 1.45; 95% confidence interval [CI] = 1.43–1.48) and decreases in red blood cell (RBC) transfusions (OR = 0.62; 0.61–0.63), endoscopies (OR = 0.60; 0.59–0.61), death (OR = 0.51; 0.48–0.54) and length of stay (relative ratio [RR] = 0.81; 0.80–0.82). Inpatient cost decreased from 2012 to 2019 (RR = 0.92; 0.91–0.93).

Conclusions: The incidence of GIB in the U.S. is increasing. UGIB incidence has been increasing since 2014 while LGIB incidence has been decreasing since 2015. Despite a more comorbid population in 2019, case fatality rate, length of stay and costs have decreased. More patients are discharged from the ED and the rate of RBC transfusions has decreased, possibly reflecting changing clinical practice in response to updated guidelines.


Gastrointestinal bleeding (GIB) is the most common cause of GI-related hospitalisation in the United States (U.S).[1] Traditionally, studies have classified GIB into upper GIB (UGIB) and lower GIB (LGIB) based on the location of the bleeding source. UGIB refers to bleeding from the esophagus, stomach or duodenum. LGIB has been defined epidemiologically as arising from sites distal to the Ligament of Treitz. In clinical practice, LGIB is now more commonly characterised as colonic bleeding with small bowel bleeding considered a separate diagnostic category.

Previous epidemiological studies have reported a low case fatality rate for GIB in the U.S. (<5%) and suggested decreasing incidence, but these studies only evaluated hospitalised patients and did not include patients who presented and were discharged from emergency departments (EDs).[2–6] Moreover, the most recent studies that reported on GIB trends over time evaluated patients through 2012 for UGIB and 2014 for LGIB.[2–6] Possible factors contributing to the decrease in UGIB incidence include Helicobacter pylori eradication and the increased use of proton pump inhibitors.[7] The most recent epidemiological study of LGIB in the U.S. suggested an increased hospitalisation rate for LGIB from 2010 to 2014, thought to be related to an ageing population and increasing frequency of antithrombotic therapy.[5,7] Furthermore, new evidence regarding the management of GIB and resultant changes in guideline recommendations (e.g., restrictive red blood cell [RBC] transfusion strategies, discharge of very low-risk patients from the ED for outpatient management) may have affected clinical practice patterns.

We believe that an updated epidemiological evaluation of the incidence and secular trends and hospital-based management and outcomes for all patients with GIB presenting to EDs in the U.S. is needed to better understand the characteristics and current state of care of patients with GIB. This study uses the National Emergency Department database to characterise epidemiological trends for GIB incidence, management and outcomes—and assesses whether real-world management has changed with the advent of new guideline recommendations.