38. Upper GI bleeding

Upper gastrointestinal bleeding

DEFINITION & CAUSES

• Upper GI bleeding originates proximal to the ligament of Treitz. It may be overt (haematemesis, coffee-ground emesis, melaena) or occasionally present as haematochezia with massive rapid bleeding.
• Common causes include peptic ulcer, erosive gastritis/duodenitis, oesophagitis, varices, Mallory–Weiss tear, malignancy and vascular lesions.
• Risk factors include NSAIDs, antiplatelets, anticoagulants, H. pylori, liver disease, alcohol-related cirrhosis and previous ulcer.

INITIAL ASSESSMENT & RESUSCITATION

• Assess airway, breathing, circulation, mental status and haemodynamic stability. Consider airway protection in massive haematemesis or reduced consciousness.
• Establish two large-bore IV lines, monitor observations, obtain full blood count, urea/creatinine, electrolytes, liver tests, coagulation profile, lactate and group/crossmatch.
• Resuscitate with IV crystalloid and blood products as indicated. Correct coagulopathy selectively and review anticoagulants/antiplatelets with specialist input.
• Use a risk score such as Glasgow-Blatchford to support triage; it does not replace clinical judgement. Restrictive red-cell transfusion is appropriate for many patients, with individualised thresholds.

DIAGNOSIS

• Upper GI endoscopy is the principal diagnostic and therapeutic test, generally performed within 24 hours after resuscitation; unstable severe bleeding may need more urgent endoscopy.
• Endoscopy identifies source and stigmata of recent haemorrhage. Peptic ulcer risk is commonly described using Forrest classification.
• If endoscopy fails or bleeding recurs, consider repeat endoscopy, CT angiography, catheter angiography with embolisation or surgery.
• Differentiate upper GI bleeding from swallowed epistaxis, haemoptysis, lower GI bleeding and iron-related dark stools.

TREATMENT

• Suspected non-variceal bleeding: start PPI according to local protocol; endoscopic haemostasis for active bleeding or visible vessel. High-dose PPI follows treatment of high-risk ulcers.
• Suspected variceal bleeding: start vasoactive therapy (e.g. terlipressin where appropriate) and prophylactic antibiotics early, then urgent endoscopy with band ligation for oesophageal varices or appropriate therapy for gastric varices.
• Persistent/recurrent bleeding may require transcatheter embolisation or surgery. Treat the underlying cause, eradicate H. pylori and stop/reduce ulcerogenic drugs where possible.
• Complications include haemorrhagic shock, aspiration, myocardial ischaemia, acute kidney injury, rebleeding and death.