Upper GI bleed

Introduction

Upper gastrointestinal bleeding refers to bleeding originating from the oesophagus, stomach, or duodenum. It is a potentially life-threatening emergency that requires prompt recognition and treatment.

Peak Incidence

• Most commonly occurs in adults aged over 75 years.

Pathophysiology

• The source of bleeding may be mucosal ulceration, vascular malformation, or varices.
• Causes include peptic ulcer disease, oesophageal varices, erosive gastritis, Mallory-Weiss tears, and upper GI malignancy.

Symptoms

• Haematemesis – vomiting of blood, which may be bright red or resemble coffee grounds.
• Malaena – black, tarry stools due to digested blood.
• Epigastric pain.
• Dyspepsia (indigestion).
• Weight loss (in cases related to malignancy).
• Dizziness or syncope due to blood loss.

Signs

• Pallor due to anaemia or blood loss.
• Haemodynamic instability:
  • Tachycardia.
  • Hypotension.
  • Signs of shock in severe cases.
• Features of chronic liver disease suggesting variceal bleeding:
  • Jaundice.
  • Ascites.
  • Hepatosplenomegaly.
  • Caput medusae.

Diagnosis

Risk Stratification

• Glasgow-Blatchford Score (Pre-Endoscopy)

  Used to assess whether inpatient treatment is required.

  • Factors: haemoglobin, urea, blood pressure, heart rate, melaena, and history of syncope.
  • Score >0 suggests need for hospital-based care.

• Rockall Score (Post-Endoscopy)

  Predicts risk of rebleeding and mortality.

  • Factors: age, haemodynamic status, comorbidities, cause of bleeding, and endoscopic findings.

Investigations

• Blood Tests:
  • Full Blood Count (FBC): May show anaemia or raised platelets (in malignancy).
  • Urea and Electrolytes: Raised urea due to digestion of blood.
  • Liver Function Tests (LFTs): Assess liver disease in suspected variceal bleeding.
  • Coagulation Screen: INR, PT, and aPTT.
  • Group and Save and crossmatch: In case transfusion is required.
• Endoscopy (Oesophagogastroduodenoscopy – OGD):
  • Gold standard for diagnosis and allows therapeutic intervention.
  • Should be performed within 24 hours of admission (earlier in unstable patients).
• Imaging (if diagnosis remains unclear or rebleeding occurs):
  • CT angiography.
  • Mesenteric angiography for embolisation in refractory cases.

Complications

• Haemodynamic instability and hypovolaemic shock.
• Iron-deficiency anaemia (in chronic or recurrent bleeding).
• Recurrent or persistent bleeding.
• Death if bleeding is not promptly managed.

Management

Initial Resuscitation (ABCDE Approach)

• Insert two large-bore IV cannulas.
• Send urgent bloods: FBC, U&Es, LFTs, coagulation profile, crossmatch.
• Administer IV fluids or blood products as appropriate.
• Activate Major Haemorrhage Protocol if required.

Transfusion and Clotting Management

• Platelet transfusion: If actively bleeding and platelets <50 × 10⁹/L.
• Fresh Frozen Plasma (FFP): If INR/aPTT >1.5× normal.
• Cryoprecipitate: If fibrinogen <1.5 g/L despite FFP.
• Prothrombin Complex Concentrate: For patients on warfarin with active bleeding.

Endoscopic Management

Non-Variceal Bleeding

• Do not administer a proton pump inhibitor (PPI) before endoscopy.
• If stigmata of recent haemorrhage are seen on OGD, administer a high-dose PPI.
• If rebleeding occurs, consider repeat endoscopy, interventional radiology, or surgery.

Variceal Bleeding

• Initiate terlipressin and prophylactic IV antibiotics before endoscopy.
• Gastric varices: Endoscopic injection of N-butyl-2-cyanoacrylate.
  • If unsuccessful, consider Transjugular Intrahepatic Portosystemic Shunt (TIPS).
• Oesophageal varices: Treated with band ligation.
• Uncontrolled bleeding:
  • Temporise with Sengstaken-Blakemore tube.
  • Proceed to TIPS if bleeding persists.

Secondary Prevention

• Propranolol for prevention of variceal rebleeding.
• Long-term PPI may be used in non-variceal bleeding to reduce recurrence.