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Upper gastrointestinal bleeds (UGI) bleeds



Aetiology of upper GI (UGI) bleeds

  • Peptic ulcer disease –  oesophageal, gastric or duodenal ulcers
    • Prevalence 4% of the population
    • Due to H. pylori, NSAID use, alcohol, steroid use, Zollinger-Ellison syndrome (gastrin-secreting tumour causing multiple ulcers)
  • Oesophagitis and gastroduodenal erosions (15%)
    • Due to aspirin, other NSAIDs, steroids
  • Oesophageal varices
    • Due to portal hypertension, usually associated with chronic liver disease
  • Portal hypertensive gastropathy
  • Mallory-Weiss tears
    • Secondary to prolonged vomiting
  • Dieulafoy’s lesion
    • Tortuous arteriole usually upper part of lesser curve, bleeding occurs through a tiny defect.
  • GORD
  • Upper GI malignancy
  • Vascular malformations
  • Aorto-enteric fistula (commonest at approx 5 years post-surgery. Approx 2% risk)


History in upper GI (UGI) bleeds

  • History of presenting complaint
    • Haematemesis – can be bright red OR coffee-ground
    • Melaena – distinctive smell, tar-like
      • Volume of blood loss in either case
    • Dyspesia
    • Dizziness
    • Chest pain
    • Prolonged vomiting/retching
    • Constitutional symptoms
  • Past medical history
    • Previous GI bleed
    • Known PUD/varices
    • Malignancy
    • Liver disease
    • Known cardiovascular/respiratory disease (fitness to undergo sedation and/or intubation for endoscopy)
  • Medications
    • NSAIDs
    • Steroids
    • Anticoagulants
  • Allergies
  • Social history
    • Alcohol consumption


Video explaining Upper GI Bleeds


Examination of upper GI (UGI) bleeds

  • Signs of chronic liver disease
  • DRE for melaena
  • Signs of shock
    • Tachycardia, hypotension, altered conscious level, postural BP (often not appropriate in acute setting)
  • Encephalopathy


Initial management of acute upper GI (UGI) bleeds

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  • Resuscitation
    • A – manage airway and consider need for intubation/airway adjunct or suctioning
    • B – give oxygen to maintain sats > 96%
    • C –
      • BP, HR
      • Large-bore IV access x 2
      • VBG to assess Hb, acidosis, lactate
      • Send lab bloods for FBC, U+Es, clotting, X-match (2-4 units usually)
      • IV fluid resuscitation (crystalloid is fine acutely)
    • D – AVPU, check glucose level
    • E – ?peritonitic abdomen
  • Imaging
    • Erect CXR to look for gas under diaphgragm
  • Catheter insertion for accurate fluid balance monitoring
  • Transfusion
    • Transfuse with x-matched (or O-neg or type-specific blood if very urgent) blood if haemodynamically unstable
    • Current guidelines suggest transfusing if Hb < 7 for patients with cirrhosis
    • If massive blood loss occurs then follow local protocols for transfusing platelets and clotting factors along with blood.
    • Give prothrombin concentrate complex to patients on warfarin who are actively bleeding
  • Proton-pump inhibitors
    • Current NICE guidance is NOT to give acid-suppression (PPIs, H2-RA) to patients with suspected non-variceal bleeds prior to endoscopy).
    • If evidence of recent haemorrhage then IV or oral PPI is given post-endoscopy
    • In practice however, this is still commonly given prior to endoscopy
  • Prokinetic
    • Metoclopramide 10mg IV can be given to empty the stomach contents to allow better views at endoscopy
  • Variceal bleeds
    • Treat as above
    • Give broad-spectrum antibiotics i.e. IV Tazocin 4.5g
    • Give IV Terlipressin 2g (unless peripheral vascular disease)
  • Endoscopy
    • Scoring system (see below)
    • Offer endoscopy to unstable patients with severe bleeding immediately after resuscitation
    • Offer endoscopy to all other patients within 24 hours
    • Management of non-variceal bleeding
      • Clips +/- adrenaline
      • Thermal coagulation with adrenaline
      • Fibrin/thrombin with adrenaline
    • Management of variceal bleeding
      • Band ligation for oesophageal varices
      • Injection of N-butyl-2-cyanoacrylate for gastric varices
      • Consider TIPSS procedure if the above methods do not control the bleeding


Further management of acute upper GI (UGI) bleeds

  • Sengstaken-Blakemore tube
    • A tube inserted into the stomach with gastric and oesophageal balloons – ONLY inflate the gastric balloon
    • Can only be used in intubated patients with varices
    • Used as a bridge for definitive therapy – usually either endoscopy or TIPSS
  • Surgical intervention
    • Perforated viscus


Scoring systems for upper GI (UGI) bleeds

  • Rockall
    • Prognosticates
    • Age, Shock, co-morbidities
      • Diagnosis and stigmata after endoscopy
    • Scores below 2 have a very low mortality
    • Scores 8 or higher have a mortality of 40%+


  • Blatchford-Glasgow
    • Risk stratify – predicts the need for hospital-based intervention
      • Urea, Hb, Systolic BP
      • Other: pulse, melaena, syncope, hepatic disease, cardiac failure
    • Use acutely but not as good as Rockall in predicting overall mortality
    • Score 0 = home
    • Score >0 = endoscopy
    • Score >5 (6 and up) = same day endoscopy


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