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HOME > Clin Endosc > Volume 58(3); 2025 > Article
Editorial Sarcopenia in the era of aging populations: its clinical implications for peptic ulcer bleeding
Hiroyuki Hisada1,2orcid, Yosuke Tsuji2,3orcid, Mitsuhiro Fujishiro2orcid
Clinical Endoscopy 2025;58(3):401-403.
DOI: https://doi.org/10.5946/ce.2025.104
Published online: May 28, 2025

1Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan

2Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

3Next-Generation Endoscopic Computer Vision, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

Correspondence: Yosuke Tsuji Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Tokyo 113-8655, Japan E-mail: ytsujitky@g.ecc.u-tokyo.ac.jp
• Received: April 7, 2025   • Revised: May 15, 2025   • Accepted: May 16, 2025

© 2025 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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See the article "Influence of sarcopenia on clinical outcomes in peptic ulcer bleeding: a retrospective single-center analysis in Korea" on page 425.
Peptic ulcer bleeding (PUB) remains one of the most common types of nonvariceal upper gastrointestinal bleeding. Although the widespread eradication of Helicobacter pylori and the use of proton pump inhibitors have led to a decline in PUB-related mortality, it continues to be a major concern, especially in elderly patients.1 To help evaluate patient outcomes, several scoring systems, such as the Glasgow-Blatchford score (GBS) and AIMS65, have been developed to assess the severity and prognosis of gastrointestinal bleeding. AIMS65 predicts in-hospital mortality in patients with upper gastrointestinal bleeding based on five factors: albumin level <3.0 g/dL, international normalized ratio >1.5, altered mental status, systolic blood pressure ≤90 mmHg, and age >65 years.2,3 In 2021, Laursen et al.4 introduced the age, blood tests, and comorbidities (ABC) score, a novel risk-stratification tool designed to predict short-term mortality in patients with gastrointestinal bleeding. The ABC score incorporates three categories: age, blood test results, including hemoglobin, blood urea nitrogen, and creatinine levels, and comorbidities, such as altered mental status, cirrhosis, and disseminated malignancy. It demonstrated superior predictive performance for 30-day mortality compared with AIMS65 in cases of upper gastrointestinal bleeding (area under receiver operating characteristics curve [95% confidence interval], 0.81 [0.78–0.83] vs. 0.65 [0.62–0.69]; p<0.001). The ABC score enables clinicians to identify patients at an increased risk of death.
With the recent aging of the population, a shift has been observed in the typical patient profile for gastrointestinal bleeding. Older adults are more likely to have comorbidities and frailty, and use medications such as nonsteroidal anti-inflammatory drugs, antiplatelet agents, and anticoagulants, all of which are known to increase the risk of gastrointestinal bleeding.5 Consequently, PUB remain a significant clinical problem despite advances in their prevention. Given these demographic and clinical changes, sarcopenia has received increasing attention as a key indicator of health status in the elderly population. Sarcopenia is a systemic skeletal muscle disorder that increases the risk of adverse outcomes including falls, fractures, disability, and mortality.6 Regarding its influence on endoscopic treatment, we have demonstrated that sarcopenia negatively affects both short- and long-term prognosis after endoscopic submucosal dissection for early cancers.7,8 However, the specific effects of sarcopenia on PUB remain unclear.
In this issue of Clinical Endoscopy, Yu et al.9 investigated the prognostic significance of sarcopenia in patients with PUB, considering its potential relevance for risk assessment. This study is the first to explore the prognostic significance of sarcopenia in patients with PUB, offering a novel perspective on the influence of chronic physiological vulnerability on acute outcomes. Between January 2014 and December 2021, 358 patients underwent esophagogastroduodenoscopy for suspected gastrointestinal bleeding, 149 (41.6%) of whom were diagnosed with sarcopenia based on computed tomography (CT). The use of CT-based muscle mass assessment reflects actual clinical practice in PUB, where CT scans are frequently performed as part of the diagnostic process, making the findings highly relevant and easy to translate into daily care. Notably, all 30-day mortalities occurred in the sarcopenia group. Furthermore, multivariate analysis identified sarcopenia, high ABC score, and administration of inotropic medications or vasopressors as independent risk factors for 30-day mortality. These findings indicate that sarcopenia is associated with an increased 30-day mortality among patients with PUB and suggest its potential utility as a risk stratification factor. However, this study had some limitations. First, sarcopenia was defined based solely on skeletal muscle mass, despite current consensus recommendations that it should be assessed using a combination of muscle mass, muscle strength, and physical performance.6,10 Second, the sarcopenia group included a higher proportion of older patients and those with a poor American Society of Anesthesiologists Physical Status classification (a system used to assess the overall physical health and fitness of patients before surgery), along with a trend toward lower serum albumin levels. Importantly, these factors are also components of the ABC score, which may have introduced potential overlap or collinearity into the analysis. Currently, the risk assessment scores for upper gastrointestinal bleeding (e.g., GBS, AIMS65, and ABC scores) do not consider sarcopenia. Therefore, future studies should evaluate whether incorporating sarcopenia into prognostic models through prospective assessments can enhance the accuracy of outcome predictions.
Therefore, investigating whether interventions targeting sarcopenia can improve the clinical outcomes in patients with PUB is essential. For example, preoperative exercise and nutritional therapy have been shown to significantly improve grip strength in elderly patients with gastric cancer, and no serious postoperative complications were observed in these patients.11 Such interventions, aimed at increasing muscle mass through nutritional support and physical activity, may facilitate recovery after gastrointestinal hemorrhage. Moreover, the effects of pre-and postoperative rehabilitation on the prognosis of gastrointestinal diseases warrant further investigation.
In clinical practice, the assessment of sarcopenia can be challenging because of time and resource constraints. However, abdominal CT, which is frequently performed during diagnostic evaluation of gastrointestinal bleeding, provides a practical opportunity to assess muscle mass by measuring the psoas muscle area. For initial screening, the AWGS 2019 guidelines for sarcopenia in Asia recommend the use of the strength, assistance with walking, rise from a chair, climb stairs, and falls (SARC-F) questionnaire, a simple five item screening tool assessing strength, assistance in walking, rising from a chair, climbing stairs, and falls, or the SARC-F with calf circumference (SARC-CalF), which is the SARC-F questionnaire combined with calf-circumference measurement to improve screening accuracy for sarcopenia.10 The use of simplified screening tools or automated imaging-based assessments may help to integrate sarcopenia evaluation into routine risk stratification.
Yu et al.9 highlighted the importance of considering sarcopenia in the risk assessment of PUB. As gastroenterologists increasingly manage older and frail patients, it is imperative to adopt a more holistic approach that integrates not only bleeding severity, but also patient-related vulnerabilities, such as sarcopenia, into risk stratification. This shift in perspective may lead to better-tailored interventions and improved outcomes. Future research should focus on validating sarcopenia as a predictive factor and exploring interventional strategies that target muscle health as part of the comprehensive care for PUB.
  • 1. Wuerth BA, Rockey DC. Changing epidemiology of upper gastrointestinal hemorrhage in the last decade: a nationwide analysis. Dig Dis Sci 2018;63:1286–1293.ArticlePubMedPDF
  • 2. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000;356:1318–1321.ArticlePubMed
  • 3. Saltzman JR, Tabak YP, Hyett BH, et al. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc 2011;74:1215–1224.ArticlePubMed
  • 4. Laursen SB, Oakland K, Laine L, et al. ABC score: a new risk score that accurately predicts mortality in acute upper and lower gastrointestinal bleeding: an international multicentre study. Gut 2021;70:707–716.ArticlePubMed
  • 5. Huang JQ, Sridhar S, Hunt RH. Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic-ulcer disease: a meta-analysis. Lancet 2002;359:14–22.ArticlePubMed
  • 6. Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019;48:16–31.ArticlePubMedPMCPDF
  • 7. Hisada H, Tsuji Y, Obata M, et al. The impact of sarcopenia on short- and long-term outcomes of endoscopic submucosal dissection for early gastric cancer. J Gastroenterol 2022;57:952–961.ArticlePubMedPDF
  • 8. Hisada H, Tsuji Y, Kuribara H, et al. Clinical meaning of sarcopenia in patients undergoing endoscopic treatment. Clin Endosc 2024;57:446–453.ArticlePubMedPMCPDF
  • 9. Yu JH, Lee HT, Jang SK, et al. Influence of sarcopenia on clinical outcomes in peptic ulcer bleeding: a retrospective single-center analysis in Korea. Clin Endosc 2025;58:425–437.Article
  • 10. Chen LK, Woo J, Assantachai P, et al. Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment. J Am Med Dir Assoc 2020;21:300–307.ArticlePubMed
  • 11. Yamamoto K, Nagatsuma Y, Fukuda Y, et al. Effectiveness of a preoperative exercise and nutritional support program for elderly sarcopenic patients with gastric cancer. Gastric Cancer 2017;20:913–918.ArticlePubMed

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        Sarcopenia in the era of aging populations: its clinical implications for peptic ulcer bleeding
        Clin Endosc. 2025;58(3):401-403.   Published online May 28, 2025
        DOI: https://doi.org/10.5946/ce.2025.104
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