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Acute Upper Gastrointestinal Bleeding

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Overview

Acute upper gastrointestinal (GI) bleeding (UGIB) describes bleeding from the oesophagus, stomach, or duodenum and is a medical emergency. An upper gastrointestinal endoscopy is crucial for its investigation.

Presentation

  • Haematemesis – vomiting blood
    • This can be bright red or described as ‘coffee grounds’
  • Melaena – describes the passage of digested blood as black, tarry stools
  • Nausea and vomiting – blood in the GI tract is pro-emetic
  • Increased urea levels:
    • Helps distinguish lower GI and upper GI bleeds as the digestion of blood increases urea
  • Signs and symptoms of associated diagnoses (e.g. stigmata of liver disease)
  • Signs of decompensation – tachycardia or hypotension
    • Heart rate is a better measure as blood pressure initially can remain normal

Risk Assessment

Risk assessment is carried out using the following scores:

  • The Blatchford score – done at first assessment:
    • This helps guide whether patients can be managed as outpatients or require urgent investigation
    • Patients with a score of 0 can be considered for early discharge
  • The full Rockall score – done after endoscopy:
    • Assesses the risk of complications and mortality based on factors such as age, blood pressure changes, comorbidities, diagnoses, and evidence of bleeding

Investigations

  • Endoscopy – diagnostic and therapeutic and is performed:
    • Immediately after resuscitation in unstable patients with acute severe UGIB
    • Within 24 hours of admission for all other patients with UGIB
  • Laboratory tests:

Differential Diagnoses

Oesophageal varices

  • Patients may vomit up fresh blood
  • They may have swallowed blood causing melaena
  • Stigmata of chronic liver disease may be present (e.g. jaundice, ascites, hepatomegaly etc.)

Oesophagitis

Upper GI malignancy

  • Constitutional symptoms are present (e.g. unexplained weight loss and night sweats)
  • Patients may have palpable masses on examination

Boerhaave syndrome

  • Patients usually have a history of repeated retching/vomiting leading to oesophageal rupture
  • Retrosternal/epigastric pain is common
  • Subcutaneous emphysema is often seen

Mallory-Weiss tear

  • Patients usually have a history of repeated retching/vomiting or coughing
  • Small streaks of bright red blood are typically seen
  • Melaena is not often seen

Peptic ulcer disease

  • Patients may have a history of NSAID and/or corticosteroid use
  • Coffee-ground vomit is often seen
  • Typical patterns may be seen:
    • Gastric ulcers – pain is worse when eating
    • Duodenal ulcers – pain is relieved when eating

Management

Initial management and resuscitation

  • Resuscitate with blood, platelets, and clotting factors as appropriate:
    • Give platelet transfusion if actively bleeding and platelet count <50 x 109/L
    • Give fresh frozen plasma if fibrinogen <1 g/L or INR, PT, or APTT >1.5 times normal
    • Give prothrombin complex concentrate to patients taking warfarin that are actively bleeding
  • Endoscopy – management varies according to the underlying cause

Endoscopic management of bleeding

  • If non-variceal bleeding:
    • Do not give proton pump inhibitors (PPIs) before endoscopy if non-variceal UGIB is suspected
    • If stigmata of haemorrhage are confirmed with endoscopy and non-variceal UGIB is present, offer a PPI
  • Options include: mechanical methods (e.g. clips), thermal coagulation, or fibrin with or without adrenaline
  • If variceal bleeding:

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