Upper GI Bleed

Exam Cram

• Acute upper GI bleeds are a core medical and surgical emergency

• Key causes: oesphageal varices in Liver Cirrhosis and Peptic Ulcers

• Presentation: haematemasis, malena, hypotensive, tachycardic

• Management: AE assessment, ask for help, consider resus bay/ periarrest pager, escalation status and massive haemorrhage protocol

Outline

Background

• Distinction between upper and lower GI bleeds is the ligament of Treitz in the duodenum

Workflow

• Symptom -> Sign -> Diagnosis -> Aetiology

• Haematemesis -> Upper GI bleed -> duodenal perforation -> NSAIDs

1. Basic Assessment 

   1. Diagnose UGIB

   2. Assess severity & stabilise

      1. Glasgow Blatchford Score

      2. Rockall

2. Investigate for underlying cause

   2. 1. Oesophageal varices

      2. Peptic ulcer

      3. Cancer- gastric, duodenal 

      4. Mallory Weiss Tear

      5. Haemophilia - note hypocalcaemia

Assessment

History

• Haematemasis (vomiting blood)- coffee ground

Examination

• Abdomen

• PR exam (sadly) is mandatory- blood on finger ?perianal disease vs malena on finger confirms UGIB

Investigations

• Anaemia, microcytic

• Raised urea- from blood breakdwon in bowels

• Creatinine could be raised

• Coagulation, LFT ?liver cirrhosis, Group & save + cross match

• Calcium- if low can interfere with clotting

• Low threshold for CTAP ?malignancy

Scores

• Glasgow-Blatchford Score- risk statifies UGIB ?discharge

• Rockall

Management

Acute

1. If Haemodynamically unstable (BP < 90/60)/ unwell

   • A-E Resuscitation, resus/ peri-arrest call/ HDU, escalation status

   • Massive transfusion protocol: 4x RBC, 4x FFP; Hb> 100, INR < 2.0; IVF, 

   • Reversal of anticoagulation

   • Emergency Gastro consult ?emergency endoscopy

   • Suspect peptic ulcers: PPI IV

   • Suspect oesphageal varices: co-amoxiclav & terlipressin

2. If stable/ well 

   • Hb > 70, or > 80 in IHD

   • Slow IVF

   • Investigate underlying cause: DW Gastro- outpatient endoscopy

Longer Term

1.  B12, folate, Fe levels & replace (once well)

2. OP Endoscopy/ colonoscopy

3. H.pylori tests

4. Oesphageal prophylactic banding

Med Reg Notes

Rebleeding at endoscopy is a key metric associated with poor outcomes. 

PPI- reduce re-bleeding after endoscopy in high risk patients. PPI useful peptic ulcers. 

References

1. Wojno KJ, Baunoch D, Luke N, Opel M, Korman H, Kelly C, Jafri SMA, Keating P, Hazelton D, Hindu S, Makhloouf B, Wenzler D, Sabry M, Burks F, Penaranda M, Smith DE, Korman A, Sirls L. Multiplex PCR Based Urinary Tract Infection (UTI) Analysis Compared to Traditional Urine Culture in Identifying Significant Pathogens in Symptomatic Patients. Urology. 2020 Feb;136:119-126. doi: 10.1016/j.urology.2019.10.018. Epub 2019 Nov 9. PMID: 31715272. 

2. Jalava J, Skurnik M, Toivanen A, et alBacterial PCR in the diagnosis of joint infectionAnnals of the Rheumatic Diseases 2001;60:287-289. 

Written in 2025