AKT · Gastroenterology/GI bleeding

Upper GI bleeding

Bleeding proximal to the ligament of Treitz (peptic ulcer commonest; varices; Mallory-Weiss)

Overview

Bleeding from the upper GI tract (proximal to the duodenojejunal flexure) — haematemesis ('coffee-ground' or fresh) and/or melaena. Commonest cause is PEPTIC ULCER; also oesophageal VARICES (cirrhosis), Mallory-Weiss tear, oesophagitis/gastritis, malignancy. Risk-stratified (Glasgow-Blatchford pre-endoscopy, Rockall post-endoscopy); resuscitate, then ENDOSCOPY within 24 h (immediately if unstable/variceal). The cause changes the drugs.

Recognise

HAEMATEMESIS (fresh red or 'coffee-ground') and/or MELAENA (black, tarry, offensive stool); haemodynamic compromise if major
Risk factors: NSAIDs/aspirin, H. pylori (ulcer), chronic liver disease/alcohol (varices), retching then vomiting blood (Mallory-Weiss)
Scores: Glasgow-Blatchford (pre-endoscopy — can identify very-low-risk for discharge), Rockall (post-endoscopy mortality)

Red flags

Haemodynamic instability/shock → major haemorrhage protocol, immediate resuscitation + urgent endoscopy
Suspected VARICEAL bleed (known/suspected cirrhosis) → terlipressin + antibiotics + urgent endoscopy

Differentials & how to tell them apart

Peptic ulcer bleedNSAID/H. pylori, endoscopic stigmata — adrenaline injection + clipping/cautery, then high-dose PPI

Variceal bleedcirrhosis/portal hypertension — terlipressin + antibiotics + band ligation

Mallory-Weiss tearforceful retching/vomiting then haematemesis — usually self-limiting

Oesophagitis/gastritis/malignancythe remaining causes on endoscopy

Investigations

Resuscitate first. FBC, U&Es (raised urea out of proportion to creatinine = upper GI blood), LFTs/clotting, group & crossmatch, VBG/lactate. Glasgow-Blatchford score. ENDOSCOPY (diagnostic + therapeutic) within 24 h (immediately if unstable).

Management

Resuscitate + risk-score (Blatchford) + endoscopy within 24 h (cause-directed therapy)

1Resuscitate (IV access, fluids/blood, correct coagulopathy; restrictive transfusion target). Calculate the Glasgow-Blatchford score; endoscopy within 24 h (immediately if unstable).Gate: If a VARICEAL bleed is suspected (cirrhosis/portal hypertension), give terlipressin + prophylactic antibiotics BEFORE endoscopy; for ulcers, high-dose PPI is given AFTER endoscopic haemostasis (not routinely before); a very low Blatchford score can allow safe outpatient management
2Ulcer: endoscopic therapy + high-dose PPI + H. pylori eradication/stop NSAIDs; varices: band ligation + terlipressin/antibiotics, then secondary prophylaxis (NSBB ± banding); rebleeding → repeat endoscopy/interventional radiology/surgery.

Resuscitation (IV access, fluids, blood; transfuse to a restrictive target ~70 g/L) — ABCs and major haemorrhage protocol first

Endoscopic haemostasis — injection + thermal/mechanical (clips) for ulcers; band ligation for varices

High-dose PPI AFTER endoscopy for ulcers — not routinely before endoscopy

Terlipressin + prophylactic antibiotics (variceal) — give EARLY if variceal bleed suspected

Key points

Haematemesis/melaena + raised urea = upper GI bleed → resuscitate, Blatchford, scope within 24 h. The cause drives drugs: ulcer (PPI after scope) vs varices (terlipressin + antibiotics early). Restrictive transfusion.

Monitor & prognosis

Haemodynamics, Hb, rebleeding (Rockall).

Good if controlled; variceal/elderly higher mortality.

Source: NICE CG141 (acute UGIB); BSG