Upper GI Bleeding: Resuscitation, Scores and Endoscopy

Upper gastrointestinal (GI) bleeding is bleeding from the oesophagus, stomach or duodenum, above the ligament of Treitz. It is a common medical emergency, and a major bleed can quickly lead to shock. Rapid resuscitation, risk assessment and early endoscopy save lives.

Causes

• Peptic ulcer disease — the most common cause, linked to H. pylori and NSAIDs.
• Oesophageal and gastric varices — in liver cirrhosis and portal hypertension.
• Oesophagitis and gastritis.
• Mallory–Weiss tear — after forceful vomiting.
• Upper GI cancers.
• Vascular lesions, such as angiodysplasia and Dieulafoy lesion.

Clinical features

• Haematemesis: vomiting fresh red blood or "coffee-ground" material.
• Melaena: black, tarry, offensive stools.
• A brisk upper GI bleed can also cause fresh red blood per rectum, together with shock.
• Signs of blood loss:
  • tachycardia
  • hypotension, including a postural drop
  • pallor
  • dizziness or fainting
  • reduced urine output
• Look for clues to the cause:
  • signs of chronic liver disease (suggesting varices)
  • NSAID, anticoagulant or antiplatelet use
  • alcohol use
  • weight loss

Immediate management

1. Assess and resuscitate (ABCDE).
   • Two large-bore IV cannulas.
   • Send bloods:
     • full blood count
     • urea and electrolytes (urea rises in upper GI bleeding)
     • liver function
     • clotting
     • group and cross-match
   • Give fluids and blood as needed.
2. Transfusion: a restrictive strategy is generally used. Transfuse at a haemoglobin of about 70 g/L, or higher (about 80 g/L) in patients with cardiovascular disease. Massive bleeding needs the major haemorrhage protocol.
3. Correct clotting problems and review anticoagulants and antiplatelets with seniors.
4. Risk assessment: the Glasgow-Blatchford score before endoscopy identifies very low-risk patients who may be managed as outpatients. The Rockall score after endoscopy predicts the risk of rebleeding and death.
5. Endoscopy within 24 hours of presentation for most patients, and immediately after resuscitation in unstable patients.

Specific treatment

• Non-variceal (ulcer) bleeding:
  • endoscopic therapy, using a combination of methods such as adrenaline injection with clips or thermal coagulation
  • followed by high-dose PPI
  • test for and treat H. pylori
  If endoscopy fails, the options are interventional radiology (embolisation) or surgery.
• Variceal bleeding:
  • terlipressin and prophylactic antibiotics before endoscopy
  • then endoscopic band ligation for oesophageal varices
  • for gastric varices, glue injection (cyanoacrylate)
  If bleeding cannot be controlled:
  • a balloon tamponade tube as a temporary bridge
  • then a TIPS procedure (transjugular intrahepatic portosystemic shunt)

Exam pearls

• Raised urea with normal creatinine suggests an upper GI bleed: digested blood protein is absorbed.
• In suspected variceal bleeding, always give terlipressin and antibiotics.
• Haemoglobin may be normal early in an acute bleed, because it has not yet been diluted.

See also Peptic Ulcer Disease, Liver Cirrhosis and our Exam Night Notes 1.0: Gastro Surgery.

Test yourself

5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.

1. Most common cause of upper GI bleeding:

   1. Varices
   2. Angiodysplasia
   3. Cancer
   4. Peptic ulcer disease
   5. Mallory–Weiss tear
   Show answer

   Answer: D. Peptic ulcer disease
   Peptic ulcers, linked to H. pylori and NSAIDs, are the commonest cause.

2. Which score identifies very low-risk patients before endoscopy?

   1. Wells
   2. CURB-65
   3. Glasgow-Blatchford
   4. Child–Pugh
   5. Rockall
   Show answer

   Answer: C. Glasgow-Blatchford
   Glasgow-Blatchford is used pre-endoscopy; Rockall is used after endoscopy.

3. Why is urea raised with normal creatinine in upper GI bleeding?

   1. Kidney failure
   2. Dehydration only
   3. Lab error
   4. Absorption of digested blood protein
   5. Liver failure
   Show answer

   Answer: D. Absorption of digested blood protein
   Blood in the gut is digested and absorbed as protein, raising urea.

4. Usual transfusion threshold in most patients with acute upper GI bleeding:

   1. Hb 70 g/L (higher, about 80, with cardiovascular disease)
   2. Never transfuse
   3. Hb 50 g/L
   4. Hb 120 g/L
   5. Always transfuse
   Show answer

   Answer: A. Hb 70 g/L (higher, about 80, with cardiovascular disease)
   A restrictive transfusion strategy improves outcomes in most patients.

5. Endoscopic treatment of choice for bleeding oesophageal varices:

   1. Adrenaline injection alone
   2. Surgery first
   3. Band ligation
   4. Argon plasma only
   5. Clips
   Show answer

   Answer: C. Band ligation
   Endoscopic band ligation is first-line for oesophageal variceal bleeding.

More articles in Gastroenterology & Hepatology

• Peptic Ulcer Disease and H. pylori: Testing and TreatmentCauses of peptic ulcers, alarm features, H. pylori breath and stool tests, eradication regimens, PPI healing and ulcer complications.
• GORD (Acid Reflux): Symptoms, When to Scope and TreatmentGastro-oesophageal reflux disease: risk factors, alarm symptoms for endoscopy, lifestyle advice, PPIs, surgery and Barrett's oesophagus.
• Hepatitis B: Transmission, Serology and TreatmentHepatitis B explained: how it spreads, interpreting HBsAg, anti-HBs and anti-HBc, chronic infection, tenofovir/entecavir and birth-dose vaccination.
• Hepatitis C: Testing and Cure with Direct-Acting AntiviralsHepatitis C in Pakistan and beyond: transmission, anti-HCV and HCV RNA testing, sofosbuvir-based cure, follow-up and prevention.

Browse all 56 articles →

Disclaimer

For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.