Upper GI Bleed (UGIB)

Exam Cram

• Definition: bleed in the GI tract proximal to the ligament of treitz at around the D3/D4 junction

• Presentation: haematemesis, melena, hypotensive, tachycardic

• Management: AE assessment, IV fluids & IV blood, stop/reverse anticoagulants, escalate care

• Key causes: peptic ulcers and oesophageal varices in liver cirrhosis

Outline

Workflow

• Symptom -> Sign -> Diagnosis -> Aetiology

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

  • A-E assessment

1. 1. Assess severity & stabilise

   2. Diagnose UGIB

   3. Investigate for underlying cause

Diagnosis

Diagnostic criteria: clinical- melena or haematemesis, iron deficiency anaemia and raised urea

Differentials: Lower GI bleed (LGIB), Haemoptysis, Sepsis, Gastroenteritis, Iron tablets (can cause black stools)

Classification: 

1. By Severity: (BP is key marker)

   • • BP < 90/60: haemodynamically unstable- requiring blood, fluids & potentially HDU/ICU for vasopressors and emergency endoscopy

     • BP > 90/60: haemodynamically stable

2. By Aetiology

   • • Oesophageal varices (liver cirrhosis)

     • Peptic ulcers

     • Cancer- gastric, duodenal, oesophagus

     • Mallory Weiss Tear

     • Haemophilias (acquired & congenital)

Assessment

History

• Haematemasis (vomiting blood)- coffee ground

• Melena, black stools, 

• Lethargy, anorexia, weight loss, 

Examination

• Epigastric tenderness ?peritonism

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

• Tachycardia, hypotensive

Investigations

• Anaemia- microcytic

• Raised urea- from blood breakdown in bowels

Scores

• Glasgow-Blatchford Score- risk statifies UGIB ?discharge

• Rockall

Management

Acute

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

   • A-E Assessment

   • Escalate care- ask for help, peri-arrest call, clarify escalation status, move to resus/ HDU/ ICU

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

   • Stop +- reversal of anticoagulation; suspend antihypertensives

   • Emergency Gastro consult ?emergency endoscopy

   • PPI IV to cover peptic ulcers

   • Co-amoxiclav & terlipressin to cover oesophageal varices

2. If stable/ well 

   • Aim Hb > 70, or > 80 in IHD

   • Slow IVF

   • IV PPI

   • Review escalation status 

   • Discuss with Gastro for inpatient vs outpatient endoscopy

   • Stop anticoagulants, review antihypertensives,

   • B12, folate, Fe levels & replace (once well); helicobacter test

Admission Cycle

Work up investigations

• Baseline bloods: FBC, U&Es, LFTs, CRP; 

• Coag, Group & save, calcium;

• ECG

• Chest XR

• VBG vs ABG

• Consider CTAP in elderly + significant abdominal pain

• Iron studies, B12, folate; H.pylori

Initial Management

• A-E: appropriate level of care & escalation status

• Severity: hemodynamic stability- massive transfusion protocol vs Hb > 70 (80 IHD)

• IV PPI (ulcer)

• Oeosophageal varices- coamoxiclav & terlipressin

• Fluid status: IVF

• Medications: anticoagulants (reversal) and antihypertensives

• Discussion with gastro: endoscopy plan (emergency vs urgent vs elective)

• Disposition

  • Level 2 (HDU): haemodynamically unstable

  • Gastro Ward: haemodynamically stable

  • Discharge: glasgow blatchford score -0

Inpatient reviews

• Await endoscopy plan- clear fluids from midnight, nil by mouth from morning

• Daily review of bowel motions, abdo pain, BP/ HR, Hb and urea

Discharge

• Criteria: stable post endoscopy (malena, BP, HR, Hb, urea)

• Follow up: consider Gastro +- outpatient endoscopy/ colonoscopy

Gastro Reg Notes

Rebleeding

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

Endoscopy report should have rebleeding plan. 

Proton pump inhibitors

PPIs reduce re-bleeding after endoscopy in high risk patients. 

PPI are effective in peptic ulcers but not in oesophageal varices. 

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