Overview
Upper gastrointestinal bleeding (UGIB) refers to gastrointestinal blood loss whose origin is proximal to the ligament of Treitz at the duodenojejunal junction.
Key presentations: Haematemesis, coffee-ground emesis, melaena, or rarely haematochezia with brisk bleeding. Case fatality is around 10%.
Causes
Common Causes
- Peptic ulcer disease (26%)
- Gastritis/erosions (16%)
- Oesophagitis (17%)
- Erosive duodenitis (9%)
High-Risk Causes
- Varices (8%) - highest mortality
- Portal hypertensive gastropathy (4%)
- Mallory-Weiss tears (3%)
- Malignancy (3%)
Clinical Features
Bleeding Manifestations
- Haematemesis (fresh or coffee-ground)
- Melaena (black, tarry stools)
- Haematochezia (rare, with brisk bleeding)
Systemic Signs
- Hypotension/tachycardia
- Weakness/fatigue
- Syncope
Chronic Liver Disease Signs
- Jaundice, spider naevi
- Ascites, caput medusae
- Encephalopathy/asterixis
Risk Assessment
Glasgow-Blatchford Score (Pre-endoscopy)
| Parameter | Points |
|---|---|
| Blood urea (mmol/L) |
|
| Haemoglobin (g/L) |
|
| Systolic BP (mmHg) |
|
| Other Markers |
|
Score 0: Consider early discharge with outpatient endoscopy
Rockall Score (Post-endoscopy)
| Parameter | Points |
|---|---|
| Age | 60-79=1, ≥80=2 |
| Shock | Tachycardia=1, Hypotension=2 |
| Comorbidities | Any=2, Severe=3 |
| Endoscopic Diagnosis | Lesion=1, Malignancy=2 |
| Bleeding Stigmata | Active bleeding=2 |
High risk: Rockall ≥3, hemodynamic instability, known varices - requires critical care admission. A total score of 8 or higher carries a high risk of mortality.
Investigations
- VBG: Rapid hemoglobin assessment
- FBC, U&E, LFTs: Baseline assessment
- Coagulation screen: Especially in liver disease
- Crossmatch: Type-specific or full crossmatch
- ECG/CXR: Assess comorbidities
- Endoscopy: Diagnostic and therapeutic
Management
Resuscitation
- Two large-bore IV lines
- Crystalloids to maintain perfusion
- Blood transfusion if Hb <70-80g/L (avoid over-transfusion)
- Platelets if <50×10⁹/L and actively bleeding
- FFP if PT/APTT >1.5×normal
- PCC for warfarin reversal
Endoscopy Timing
- Unstable patients: Immediate after resuscitation
- All others: Offer endoscopy within 24 hours of admission
Non-Variceal Bleeding
Endoscopic Therapy
- Mechanical (clips) ± adrenaline
- Thermal coagulation + adrenaline
- Fibrin/thrombin + adrenaline
Note: Do not use adrenaline as monotherapy
Medical Therapy
- PPI after endoscopy (not before)
- Consider repeat endoscopy if high rebleed risk
Variceal Bleeding
Pharmacological
- Terlipressin for 5 days
- Prophylactic antibiotics
Endoscopic
- Oesophageal varices: Band ligation
- Gastric varices: N-butyl-2-cyanoacrylate
Rescue Therapies
- Balloon tamponade (Sengstaken-Blakemore)
- TIPS if uncontrolled bleeding
Secondary Prevention
- NSAIDs: Stop during acute phase
- Clopidogrel: Individual risk-benefit assessment
- Aspirin: Continue for secondary prevention if haemostasis achieved
- Varices: NSBB (propranolol/nadolol) + band ligation
- H. pylori: Test and treat if present
Upper GI Bleeding Management Algorithm