Gastroenterology & Nutrition

Upper Gastrointestinal Bleeding

Bleeding above the ligament of Treitz, where the lesion (an acid-eroded artery or a ruptured portal-hypertensive varix) decides which of two entirely different drug pathways the patient needs.

In a nutshell

Haematemesis or melaena with two completely different drug pathways: non-variceal bleeding needs endoscopic haemostasis then a high-dose proton pump inhibitor (PPI); variceal bleeding needs terlipressin and antibiotics started on suspicion. Resuscitate, transfuse only below a haemoglobin of 70 g/L, calculate a Glasgow-Blatchford score, and endoscope within 24 hours, or 12 hours if varices are suspected.

Classic presentation

Coffee-ground vomiting and black tarry melaena in an older patient taking an NSAID, or fresh haematemesis in someone with known alcohol-related liver disease and ascites.

Key points

Urea rises out of proportion to creatinine because digested blood is an absorbed protein load; it points to an upper source.
Melaena is black, tarry and offensive from digested blood, and is not the same as the dark stool caused by oral iron.
Haemoglobin can be normal in the first hours: whole blood is lost in proportion until plasma dilution catches up.
Terlipressin duration is disputed: NICE CG141 allows up to 5 days, but the BNF licensed maximum for Glypressin is 48 hours.
Antibiotics go to everyone with suspected or confirmed variceal bleeding, not only to those with proven infection.
A Mallory-Weiss tear follows forceful retching or vomiting and usually stops without endoscopic treatment.
In cirrhosis, blood in the gut is a protein load that precipitates hepatic encephalopathy as well as causing hypovolaemia.

First-line investigation

Urgent FBC, U&E, LFT, clotting and venous lactate with group and crossmatch, feeding straight into a Glasgow-Blatchford score at the bedside.

Management

Resuscitate and decide which pathway

Two large-bore cannulae, bloods, group and crossmatch, continuous monitoring, senior help. Protect the airway: active haematemesis or reduced consciousness needs anaesthetic review and often intubation before endoscopy.^1,3
Transfuse red cells below haemoglobin 70 g/L, target 70 to 100 g/L. Platelets if bleeding with a count below 50 x 10^9/L. Fresh frozen plasma if INR or clotting times exceed 1.5 times normal.^3,1
Do not give tranexamic acid. Withhold pre-endoscopy proton pump inhibitor (PPI) therapy in suspected non-variceal bleeding. Stop NSAIDs; continue low-dose aspirin once haemostasis is achieved.^7,1

Score, and reverse anticoagulation

The Glasgow-Blatchford score at first assessment uses urea, haemoglobin, systolic blood pressure, pulse, melaena, syncope, liver disease and heart failure. It asks whether the patient needs hospital at all.^1,4
Score 0 supports early discharge (NICE CG141); the British Society of Gastroenterology (BSG) care bundle extends this to 0 or 1. The full Rockall score, after endoscopy, predicts rebleeding and death.^1,3,4
Active warfarin bleeding: give prothrombin complex concentrate. For life-threatening or uncontrolled DOAC bleeding, stop the drug, involve haematology, consider andexanet for eligible apixaban or rivaroxaban gastrointestinal bleeding, and give idarucizumab 5 g intravenously for dabigatran.^1,12,13
Use recombinant factor VIIa only after every other option has failed.¹

Variceal pathway: drugs before the endoscope

Known or suspected advanced chronic liver disease: terlipressin 2 mg IV every 4 hours (1 mg if not tolerated) plus ceftriaxone 1 g IV once daily, both started on suspicion, not on confirmation.^1,6,8,5
Avoid terlipressin in pregnancy and in septic shock with low cardiac output; use caution in ischaemic heart, cerebrovascular or peripheral vascular disease. Octreotide is the off-licence alternative.^14,2
Endoscopy within 12 hours for suspected varices, extending to 24 hours only if stable. Band ligation for oesophageal varices; glue, thrombin or radiological obliteration for gastric and ectopic varices.^2,8

Non-variceal pathway and rescue

Endoscopy immediately after resuscitation if unstable, otherwise within 24 hours. Treat a high-risk ulcer with two modalities; adrenaline injection alone is never enough.^1,3
After endoscopic haemostasis of an ulcer with stigmata of recent haemorrhage: omeprazole 80 mg IV over 40 to 60 minutes, then 8 mg/hour for 72 hours, then oral.^1,15
Rebleeding: repeat endoscopy, then radiological embolisation, then surgery. Uncontrolled variceal bleeding: covered stent or balloon tamponade with a protected airway, bridging to rescue transjugular intrahepatic portosystemic shunt (TIPSS).^1,2

Prevent the next bleed

Bleeding peptic ulcer: test for Helicobacter pylori and eradicate with a PPI plus amoxicillin 1 g twice daily and clarithromycin 500 mg or metronidazole 400 mg twice daily, for 7 days.^10,11
After variceal bleeding: repeat band ligation every 2 to 4 weeks until obliteration, plus a non-selective beta-blocker (maintenance carvedilol 6.25 to 12.5 mg daily) and hepatology follow-up.²

Exam traps

Tranexamic acid helps in trauma and postpartum haemorrhage but not here: HALT-IT found no survival benefit and more clots and seizures.
Do not give a proton pump inhibitor before endoscopy in suspected non-variceal bleeding, however tempting; NICE CG141 is explicit.
A normal blood pressure and a normal first haemoglobin do not exclude major haemorrhage.
The Glasgow-Blatchford score is pre-endoscopy; the full Rockall score cannot be completed until the endoscopist has looked.
Adrenaline injection alone is not definitive treatment for a high-risk ulcer: a second modality is required.
Terlipressin causes ischaemia. Avoid it in pregnancy and in septic shock with low cardiac output.
Antibiotics go to every suspected variceal bleed in cirrhosis, whether or not infection is evident.
Balloon tamponade and covered stents are bridges to TIPSS, never definitive treatment, and need a protected airway.

Illustrations

Anatomical branch point: ulcer versus variceal bleedingDiagram contrasting acid-eroded vessel bleeding from a peptic ulcer with rupture of portosystemic collateral varices in portal hypertension.PassFinals · original

Deep gastric ulcer at endoscopyEndoscopic view of a deep gastric ulcer, the commonest non-variceal source of acute upper gastrointestinal bleeding.User:Samir, Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.