Level 2 of 6Must-remember

Upper gastrointestinal bleeding

Assess, manage and stay safe — enough on its own

1 / 9

The card — assess, manage, caution

Assessment— look, ask, measure

Recognise the two cardinal presentations: haematemesis is vomiting of blood — red with clots when bleeding is rapid and profuse, black or coffee-ground when it is slower — and melaena is black, tarry, characteristically offensive stool implying bleeding from any lesion proximal to the right colon.
Ask what was vomited and when: a large volume of dark red blood vomited without preceding retching in a patient with stigmata of liver disease is variceal until proved otherwise, whereas vomiting food first and blood only after several retches (classically after alcoholic dry heaves) is a Mallory–Weiss tear.
Ask about syncope — caused by hypotension from volume depletion, it marks significant loss — and about exertional breathlessness, fatigue or angina, which suggest chronic or subacute bleeding.
Take the drug history carefully: aspirin even at 75 mg daily and every other NSAID produce ulcers and erosions, patients frequently do not know their pain tablet is an NSAID, glucocorticoids plus NSAIDs act synergistically, and anticoagulants and antiplatelets do not cause bleeds but make every bleed greater.
The decisive clinical question is whether this patient has liver disease, because it determines the vasoactive drug, the antibiotic, the transfusion target and the prognosis — look deliberately for jaundice, spider naevi, palmar erythema, leuconychia, gynaecomastia, testicular atrophy, Dupuytren's contracture, caput medusae, ascites, peripheral oedema, asterixis and confusion.
Splenomegaly is the cardinal finding of portal hypertension — the diagnosis is unusual when the spleen cannot be detected clinically or on ultrasound, although in adults it is rarely more than 5 cm below the left costal margin.Not available at your setup — Ultrasound. If ultrasound is unavailable, assess for splenomegaly by careful clinical palpation and percussion.
Measure the bedside markers of shock: pallor, a cold nose and peripheries, systolic blood pressure below 100 mmHg and a pulse above 100 beats/min, with oliguria, sweating, agitation or reduced consciousness; severe bleeding causes tachycardia, hypotension and oliguria and the patient is cold and sweating.
Rectal examination is mandatory in every patient to establish stool colour — melaena, haematochezia or brown.
Examine the abdomen for a second emergency: significant tenderness with peritoneal irritation — involuntary guarding, rigidity — suggests perforation.
Assess the airway before anything else: blood in the pharynx of a drowsy or shocked patient is lethal, and aspiration rather than exsanguination is the commonest preventable death.
Send the bloods that grade severity: full blood count (the haemoglobin may be normal after sudden major bleeding until haemodilution occurs, so a normal value in the first hour excludes nothing), urea and creatinine (an elevated urea with a normal creatinine implies severe bleeding), liver function, albumin, PT/INR, group and cross-match, and a blood gas for lactate, base deficit and a point-of-care haemoglobin.Doctor / NurseNot available at your setup — Renal function (creatinine/urea), Liver function tests, Coagulation (PT/INR), Arterial blood gas.
Score before endoscopy with the modified Blatchford score, which uses only pre-endoscopic data: a score of 2 or less carries a very low risk of adverse outcome and identifies patients who may be managed without immediate inpatient intervention.
Know the red flags: inability to protect the airway; repeated large-volume haematemesis; shock; syncope at presentation; a haemoglobin that will not rise despite transfusion; any stigma of chronic liver disease; abdominal guarding suggesting perforation; and an aortic graft or aneurysm, in which a small herald bleed precedes an exsanguinating one.
Adjust for age: in a fit young adult compensation is excellent and then abruptly fails so hypotension may be a late finding and tachycardia and postural change must be believed, while in the elderly beta-blockers and rate-limiting calcium antagonists mask the tachycardia and presentation may be with collapse, falls, confusion or angina rather than visible blood.
In children, blood pressure falls late — use tachycardia, capillary refill beyond 2 seconds, cool peripheries, reduced urine output and altered behaviour, and treat bradycardia in a shocked or hypoxic child as a pre-arrest sign; in a neonate or breastfed infant blood in the vomit is usually swallowed maternal blood, and the alternative is vitamin K deficiency bleeding of the newborn.
Exclude the impostors: haemoptysis (blood coughed, bright red and frothy, mixed with sputum, alkaline, no melaena), swallowed epistaxis, red vomitus that is not blood (beetroot, tomato, red drinks, food colouring), and black stool that is not melaena (iron or bismuth — black but neither tarry nor offensive, so test and smell it).

Management— do this, in order

Position and protect the airway first: sit the conscious patient up, put the obtunded patient in the left lateral position, keep suction to hand, and consider tracheal intubation before endoscopy in repeated recent haematemesis — particularly with suspected variceal haemorrhage, reduced consciousness from shock, encephalopathy or alcohol, refractory hypoxaemia, or any plan for balloon tamponade.Doctor / NurseNot available at your setup — Endotracheal intubation kit. If intubation is unavailable, position left lateral, keep suction constantly ready and escalate urgently.
Oxygen: monitor saturations by pulse oximetry with a target of 94–98%, using high-flow oxygen via a reservoir mask in shock.
Access and bloods: two large-bore intravenous cannulae, 16 gauge or larger; send full blood count, urea, electrolytes and creatinine, liver function tests, prothrombin time with INR, group and cross-match (at least 2 units if a significant bleed is suspected, 4 or more if shocked or varices are suspected), and blood cultures where liver disease is suspected. Nothing by mouth until endoscopy.Doctor / NurseNot available at your setup — Renal function (creatinine/urea), Liver function tests, Coagulation (PT/INR), Blood culture.
Fluids in an unstable adult: a 500 mL bolus of crystalloid (0.9% sodium chloride or a balanced solution) over less than 15 minutes, reassessing pulse, blood pressure, capillary refill and conscious level after every bolus — avoid indiscriminate large-volume crystalloid, which causes dilutional coagulopathy and hypothermia and worsens ascites in cirrhosis.
Fluids in a shocked child: 10 mL/kg boluses of 0.9% sodium chloride, reassessed after each; if the child remains shocked after 20 mL/kg, move to packed red cells 10 mL/kg.Not available at your setup — Blood & blood products.
Transfuse to physiology rather than to a number, using a restrictive threshold by default: below 70 g/L for most patients (higher with haemodynamic instability or ischaemic heart disease), below 90 g/L in high-risk patients such as the elderly and those with coronary artery disease, and a target of 80 g/L in cirrhosis — and remember a hypovolaemic patient with a normal haemoglobin may still need blood.Doctor / NurseNot available at your setup — Blood & blood products.
Correct coagulopathy in parallel with resuscitation: platelets if the count is below 50 × 10⁹/L with active bleeding or haemodynamic instability, or with platelet dysfunction from chronic aspirin; fresh frozen plasma if fibrinogen is below 1 g/L or the PT/INR or APTT exceeds 1.5 times normal; prothrombin complex concentrate if the patient takes warfarin and is actively bleeding, together with vitamin K (phytomenadione) 5–10 mg by slow intravenous injection, rechecking the INR after reversal.Doctor / NurseNot available at your setup — Coagulation (PT/INR), Blood & blood products.
Stop the direct oral anticoagulant and record the time of the last dose: half-lives with normal renal function are rivaroxaban 5–9 hours, apixaban 8–15 hours, dabigatran 12–14 hours and edoxaban 10–14 hours, so most GI bleeds settle with resuscitation, blood products and cessation of the drug.Doctor
Give a proton pump inhibitor to every upper GI bleed before the cause is known: pantoprazole, omeprazole or esomeprazole 40 mg IV twice daily; paediatric dose omeprazole or pantoprazole 1 mg/kg IV once daily to a maximum of 40 mg.Doctor / Nurse
If the bleeding may be variceal, give the vasoactive drug immediately, before endoscopy: terlipressin 2 mg IV every 6 hours until bleeding stops, then 1 mg every 4–6 hours, continued up to 72 hours — the only vasoconstrictor proven to reduce mortality.Doctor / Nurse
Where terlipressin is unavailable or contraindicated (ischaemic heart disease): octreotide 50 microgram IV bolus then 50 microgram/hour by infusion for 2–5 days, or somatostatin 250–500 microgram/hour by infusion; in children use octreotide 1 microgram/kg IV bolus (maximum 50 microgram) then 1 microgram/kg/hour.Doctor / NurseNot available at your setup — Infusion pump.
Antibiotic prophylaxis is mandatory in cirrhosis and improves survival: ceftriaxone 1 g IV once daily, stepping down to ciprofloxacin 500 mg orally every 12 hours when the patient is eating, for a total course of 5–7 days; alternatives cefotaxime 1–2 g IV every 8 hours or piperacillin–tazobactam 4.5 g IV every 8 hours; in children ceftriaxone 50 mg/kg IV once daily, but cefotaxime 50 mg/kg IV every 8 hours in a neonate under 28 days receiving calcium-containing fluids or in a jaundiced neonate.Doctor / Nurse
Supportive measures in cirrhosis: a phosphate enema and/or lactulose 10–30 mL orally or by nasogastric tube three times daily titrated to two soft stools daily; anticipate alcohol withdrawal and treat with lorazepam or oxazepam rather than chlordiazepoxide; give intravenous thiamine to any patient with an alcohol history before glucose-containing fluid.Doctor / Nurse
Before endoscopy in severe bleeding, clear the stomach: erythromycin 3 mg/kg IV over 20 minutes, or metoclopramide 10 mg IV, given 30–90 minutes beforehand.Doctor / Nurse
Endoscopy after adequate resuscitation, ideally within 24 hours, and immediately after resuscitation if the patient is unstable — band ligation for oesophageal varices, cyanoacrylate glue or thrombin for gastric varices, and dilute adrenaline combined with thermal coagulation or endoscopic clipping for high-risk ulcers, because adrenaline alone is insufficient.Doctor
After endoscopy for a high-risk ulcer (active bleeding, visible vessel, adherent clot, or any ulcer requiring endoscopic haemostasis): PPI 80 mg IV bolus followed by 8 mg/hour for 72 hours; where an infusion is impractical use intermittent intravenous PPI or high-dose oral PPI — omeprazole 40 mg once daily, pantoprazole 40 mg twice daily, lansoprazole 30 mg twice daily, rabeprazole 20 mg twice daily or esomeprazole 40 mg once daily.Doctor / NurseNot available at your setup — Infusion pump.
If first-line treatment fails, repeat endoscopy once; balloon tamponade is a bridge to definitive therapy only — intubate first, pass a Minnesota or Sengstaken–Blakemore tube through the mouth, inflate the gastric balloon with 200–250 mL of air ideally under direct endoscopic vision, apply gentle traction, keep any oesophageal balloon below 40 mmHg deflating for about 10 minutes every 3 hours, and leave the tube in place for no more than 12 hours.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
Monitor hourly with pulse, blood pressure, oxygen saturation and urine output, repeating the full blood count, coagulation screen and urea and electrolytes after significant transfusion or any deterioration — rebleeding declares itself as a rising pulse before anything else.

Caution— what harms

Aspiration of blood is the commonest preventable cause of death and follows vomiting in a supine, drowsy or encephalopathic patient — never leave a patient vomiting blood flat and unattended.
A normal haemoglobin in the first hour excludes nothing, because anaemia does not develop until haemodilution has taken place; treat the physiology, not the number.
Do not over-transfuse in cirrhosis: over-transfusion raises portal pressure and provokes early rebleeding, baroreceptor reflexes are blunted, and over-correction is as dangerous as under-correction — target 80 g/L.
Avoid indiscriminate large-volume crystalloid: dilutional coagulopathy and hypothermia make a bleeding patient bleed harder, and excessive saline worsens ascites in cirrhosis. Monitor for circulatory overload, particularly in the elderly.
Terlipressin is contraindicated in ischaemic heart disease and used with caution in peripheral and cerebrovascular disease; expect abdominal colic, an urge to defecate and facial pallor from generalised vasoconstriction, and check the serum sodium because it causes hyponatraemia.
Do not assume liver disease means varices: about 20% of patients with chronic liver disease who bleed are bleeding from a non-variceal lesion, and peptic ulceration is commoner in liver disease than in the general population — where the question cannot be settled clinically, treat as variceal AND give a proton pump inhibitor.
Do not omit antibiotics in a cirrhotic bleeder: sepsis is common and prophylaxis reduces early rebleeding and mortality; send a full septic screen including a diagnostic ascitic tap where ascites is present, but do not delay the antibiotic for it.
Tranexamic acid is not routine and must not be given reflexively as it is in trauma — the large HALT-IT trial found no mortality benefit and an excess of venous thromboembolism and seizures.
A clear nasogastric aspirate does not exclude an upper GI bleed, because a duodenal ulcer may bleed beyond a closed pylorus; it does not usefully alter management.
Never inflate the gastric balloon without confirming its position: inadvertent inflation in the oesophagus causes oesophageal rupture, endotracheal intubation before insertion is mandatory, and tamponade is a bridge, never a treatment.
Think before stopping antiplatelet therapy: stopping antiplatelets can be dangerous and may produce thrombosis; stop everything in life-threatening bleeding, otherwise weigh bleeding against stent thrombosis and reintroduce antithrombotic therapy early, aiming to restart both agents of dual antiplatelet therapy within 5–7 days in patients with coronary stents.
In cirrhosis the INR reflects synthetic function, not bleeding tendency — it is a prognostic marker that does not by itself justify plasma transfusion.
A negative *H. pylori* urease test in the acute setting is unreliable (a positive test is valid) — proceed to histology, or repeat with a urea breath or faecal antigen test after recovery.
A patient who has stopped bleeding is not cured: watch for a rising pulse, falling blood pressure, fresh haematemesis or melaena, falling urine output, a haemoglobin that will not rise, and new restlessness or confusion — and before discharge arrange *H. pylori* eradication, 4 weeks of PPI, permanent NSAID avoidance and confirmation of eradication.

Refer / escalate

Refer for urgent endoscopy and higher-level care if the patient is shocked, has repeated large-volume haematemesis, cannot protect the airway, has any stigma of chronic liver disease or suspected varices, has a haemoglobin that will not rise despite transfusion, has abdominal guarding suggesting perforation, has an aortic graft or aneurysm, or has a modified Blatchford score above 2 or a pre-endoscopy Rockall score above 1 — and escalate immediately for balloon tamponade, TIPS, embolisation or surgery when bleeding continues after a repeat endoscopy.

The card — assess, manage, caution

Upper gastrointestinal bleeding — Level 1: CorePrevious Upper gastrointestinal bleeding — Level 3: Core practiceNext

Read the full lesson free

Create a free account to unlock every page, the level exams, and progress tracking.