AKT · Acute care/GI bleed, burns & trauma

Upper GI bleeding

Peptic ulcer or variceal bleeding (commonest)

Overview

Bleeding proximal to the ligament of Treitz — haematemesis/melaena. Risk-stratified by the Glasgow-Blatchford score (pre-endoscopy) and Rockall (post-endoscopy); variceal and non-variceal bleeds diverge in management (terlipressin + antibiotics for varices).

Recognise

Haematemesis (fresh or coffee-ground), melaena, haemodynamic compromise
Peptic ulcer (NSAIDs/H. pylori) vs variceal (chronic liver disease, stigmata)
Hypotension/tachycardia, raised urea (digested blood)

Red flags

Shock, ongoing haematemesis, chronic liver disease (variceal), low Blatchford threshold for admission

Differentials & how to tell them apart

Variceal bleedchronic liver disease/portal hypertension → terlipressin + prophylactic antibiotics + band ligation

Peptic ulcer bleedNSAID/H. pylori; endoscopic haemostasis + high-dose PPI

Mallory-Weiss tearvomiting/retching then haematemesis; usually self-limiting

Malignancyweight loss, dysphagia, anaemia

Investigations

Glasgow-Blatchford score (decides admission/urgency), FBC, U&E (raised urea), LFTs, clotting, group & crossmatch; upper GI endoscopy (diagnostic + therapeutic); Rockall after endoscopy.

Management

Resuscitate + Blatchford score → endoscopy; variceal: terlipressin + antibiotics + banding

1ABCDE + resuscitate (crossmatch, restrictive transfusion). Calculate the Glasgow-Blatchford score; arrange upper GI endoscopy (within 24 h, or immediately if unstable).Gate: If a VARICEAL bleed is suspected (chronic liver disease) → give terlipressin AND prophylactic antibiotics before/at endoscopy, then band ligation — antibiotics improve survival
2Non-variceal/ulcer: endoscopic haemostasis + high-dose PPI after endoscopy; test/treat H. pylori; stop NSAIDs. Varices: secondary prophylaxis (beta-blocker + banding).

Terlipressin + prophylactic antibiotics — suspected VARICEAL bleed (before/at endoscopy)

Proton pump inhibitor — after endoscopy for non-variceal/ulcer bleeding (not routinely before)

Blood/tranexamic-acid per protocol — resuscitate; transfuse to a restrictive target

Key points

Blatchford pre-endoscopy (a score of 0 may allow outpatient management); Rockall post-endoscopy for rebleed/mortality risk. Antibiotics in variceal bleeding reduce mortality.

Monitor & prognosis

Haemodynamics, Hb, rebleeding signs, transfusion response.

Variceal bleeds carry higher mortality; risk scores guide care.

Source: NICE CG141 (acute upper GI bleeding)