■ Feature Article

Upper Gastrointestinal Bleeding After

Hip and Knee Arthroplasty
SUNIL SHARMA, FRCS(GLAS), FRCS(ED)

abstract
The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and anticoagulants perioperatively. Any record of hematemesis
increases the risk of upper gastrointestinal bleeding. This article assesses its inci- and melena in the postoperative period was
dence in patients undergoing hip and knee arthroplasty. A single-center, retro- evidence of upper gastrointestinal bleeding.
spective study was conducted on 100 consecutive hip and 100 consecutive knee Endoscopy records were used to record the
arthroplasties performed at the Victoria Infirmary, Glasgow, between 1998 and cause of bleeding. Admission and discharge
2000. Sixty-three percent of patients were women with a mean age of 74. Fifty- dates provided details of length of hospital
four percent of patients received NSAIDs and all patients received anticoagulants stay. We excluded patients having revision
perioperatively. Four and a half percent of patients had upper gastrointestinal hip or knee arthroplasty from this study.
bleeding postoperatively. We believe that the incidence of upper gastrointestinal
bleeding as a complication is underestimated and recommend gastro-protective RESULTS
agents in the perioperative period for patients on NSAIDs. The patients consisted of 126 women
and 74 men with an average age of 74 years
(range: 41-86 years). Osteoarthritis was the
MATERIALS AND METHODS

A
cute mortality from gastrointes-
tinal bleeding can be as high as
14%. The predisposing factor for
gastrointestinal bleeding is long-term use
of non-steroidal anti-inflammatory drugs
(NSAIDs) that can increase the incidence
of upper gastrointestinal bleeding by four
to six fold on average. Advanced age, an-
ticoagulants, and co-morbid diseases are
other predisposing factors.1-3 Patients with
hip and knee arthritis who are admitted
for joint replacement surgery have at least
one of these predisposing factors and are
therefore at a risk of perioperative gastroin-
testinal bleeding. Although this complica-
tion is known to occur after hip and knee
arthroplasty, its incidence and effects on
the outcome of the procedure are unknown.
This article estimates the incidence of this
problem.
The records of 100 consecutive total hip
arthroplasties (THAs) and 100 consecu-
tive total knee arthroplasties (TKAs) per-
formed at the Victoria Infirmary, Glasgow,
between 1998 and 2000 were reviewed.
Information about the diagnostic and de-
mographic characteristics of the patients,
use of NSAIDs, prophylactics used against
deep vein thrombosis (DVT), the incidence
of gastrointestinal bleeding in these patients
in the perioperative period, and the effect
of this complication on outcome of arthro-
plasty were gathered. Preoperative records
containing the patients’ medical history and
physical examination were used to assess
the incidence of previous gastrointestinal
problems, use of NSAIDs, and gastro-pro-
tective drugs. The patients’ drug charts
provided information on the drugs used
diagnosis in 84 patients who underwent
THA and 92 patients who underwent TKA.
Rheumatoid arthritis was the diagnosis in 16
patients who underwent THA and 8 patients
who underwent TKA. In 108 patients, non-
steroidal anti-inflammatory drugs were used,
such as diclofenac sodium (63), ibuprofen
(29), cox-2 inhibitors (9), and others (7). All
200 patients received prophylactics against
DVT. Seventy-eight patients received 150
mg of aspirin and 122 patients received 20
mg of subcutaneous low-molecular heparin
during their hospital stay. The anticoagulant
treatment chosen for the patient was based
Mr Sharma is from the Glasgow Royal Infir-
mary and Victoria Infirmary, Glasgow, Scotland,
United Kingdom.
Reprint requests: Sunil Sharma, FRCS(Glas),
FRCS(Ed), 47 Shuna Place, Newton Mearns,
Glasgow, G77 6TN, Scotland, UK.

MARCH 2006 | Volume 29 • Number 3 255