🩸 Initial Management of Upper GI Bleed (Shock, Haematemesis, Melaena)
🫁 Oxygen: 15 L/min via non-rebreathe mask (target SpO₂ ≥94%; ≥88% if COPD). 💉 IV Access: 2 large-bore (14–16G) cannulae; start warmed IV crystalloids. ➡️ If cirrhosis → use albumin/colloid cautiously. 🧪 Bloods: FBC, U&E, LFT, clotting, glucose, crossmatch 4–6 units. Monitor Hb every 6 h. ⛔ Reverse anticoagulants/coagulopathy: – Warfarin → Vit K 5–10 mg IV + PCC (Octaplex) 25–50 IU/kg. – DOACs → Idarucizumab (dabigatran) 5 g IV; Andexanet alfa (apixaban/rivaroxaban). – Platelets if <50 x 10⁹/L; FFP if INR >1.5; Cryoprecipitate if fibrinogen <1.5 g/L. 🚨 Exsanguinating bleed: Activate Major Haemorrhage Protocol → O negative blood. 📊 Risk stratify: Glasgow–Blatchford score at presentation. 🩺 Variceal bleed: IV Terlipressin 2 mg IV every 4 h (max 72 h) + IV Cefotaxime 1 g TDS. 💊 Non-variceal bleed: IV PPI (Omeprazole 80 mg IV bolus → 8 mg/hr infusion × 72 h). 🦠 Cirrhotic with ascites: Give prophylactic antibiotics (Cefotaxime 1 g TDS or Ceftriaxone 1 g OD).

🩸 Initial Management of Upper GI Bleed (Shock, Haematemesis, Melaena)

🫁 Oxygen: 15 L/min via non-rebreathe mask (target SpO₂ ≥94%; ≥88% if COPD).
💉 IV Access: 2 large-bore (14–16G) cannulae; start warmed IV crystalloids. ➡️ If cirrhosis → use albumin/colloid cautiously.
🧪 Bloods: FBC, U&E, LFT, clotting, glucose, crossmatch 4–6 units. Monitor Hb every 6 h.
⛔ Reverse anticoagulants/coagulopathy: – Warfarin → Vit K 5–10 mg IV + PCC (Octaplex) 25–50 IU/kg. – DOACs → Idarucizumab (dabigatran) 5 g IV; Andexanet alfa (apixaban/rivaroxaban). – Platelets if <50 x 10⁹/L; FFP if INR >1.5; Cryoprecipitate if fibrinogen <1.5 g/L.
🚨 Exsanguinating bleed: Activate Major Haemorrhage Protocol → O negative blood.
📊 Risk stratify: Glasgow–Blatchford score at presentation.
🩺 Variceal bleed: IV Terlipressin 2 mg IV every 4 h (max 72 h) + IV Cefotaxime 1 g TDS.
💊 Non-variceal bleed: IV PPI (Omeprazole 80 mg IV bolus → 8 mg/hr infusion × 72 h).
🦠 Cirrhotic with ascites: Give prophylactic antibiotics (Cefotaxime 1 g TDS or Ceftriaxone 1 g OD).

➡️ Endoscopy: Immediately if unstable. ⚠️ All others within 24 h. If life-threatening bleed despite endoscopy → emergency IR embolisation or surgery.

📊 Incidence

UK incidence: 80–170 per 100,000/year.
~50,000–70,000 hospital admissions/year.
Mortality ~10% (higher in varices & elderly).

🩺 Clinical Terminology

Haematemesis: Vomiting fresh blood (UGIB).
Coffee Grounds: Black vomit due to gastric acid altering blood.
Melaena: Black, tarry stool (sticky, foul smell).
Haematochezia: Bright PR blood (usually LGIB, but may be rapid UGIB).

🚨 Major Bleed Signs

Pulse >100, SBP <100, postural drop >20 mmHg.
Clammy, cold peripheries, drowsy/confused.
Haematemesis or melaena on exam.
Shock disproportionate to Hb drop (Hb may lag early).

⚠️ Risk Factors for Poor Outcome

Age >60, frailty.
Persistent melaena/haematemesis.
Hypotension despite resus.
Liver disease/varices, malignancy, renal/cardiac failure.

🔎 Causes of UGIB

Non-variceal (90%): Peptic ulcer disease (50%), gastritis/duodenitis, erosions (NSAIDs, steroids, alcohol, H. pylori), Mallory–Weiss tear, Dieulafoy lesion, vascular ectasia, gastric malignancy.
Variceal (10%): Oesophageal/gastric varices from portal hypertension (alcoholic cirrhosis, viral hepatitis, NASH).

🧪 Investigations

Bloods: FBC, U&E, LFTs, clotting, group & save, amylase (exclude pancreatitis).
↑ Urea: disproportionate to creatinine (digested blood absorption).
ECG: exclude ACS (demand ischaemia common).
Endoscopy: Diagnostic + therapeutic.

📏 Risk Scores

Glasgow–Blatchford Score (GBS): at presentation. – 0 = safe discharge if stable. – ≥1 = admit + endoscopy.
Rockall Score: after endoscopy. – <3 = low risk, >8 = poor prognosis.

💊 Specific Therapies

Non-variceal bleed: – Endoscopic therapy: adrenaline injection, clips, thermal coagulation. – PPI: Omeprazole 80 mg IV bolus → 8 mg/hr infusion × 72 h. – Long-term: H. pylori eradication (PPI + Amoxicillin 1 g BD + Clarithromycin 500 mg BD × 7 days).
Variceal bleed: – Terlipressin 2 mg IV every 4 h (max 72 h). – Cefotaxime 1 g IV TDS (SBP prevention). – Endoscopic band ligation (preferred) or sclerotherapy. – If uncontrolled: Sengstaken tube, TIPSS.
Cirrhotics: Avoid excessive saline → risk of ascites/hyponatraemia. Use blood products carefully.

⚕️ Escalation

Failure of endoscopy → Interventional Radiology (embolisation).
Failure of IR → emergency surgery (subtotal gastrectomy / oversewing ulcer).

📚 Exam Pearls

Painless large-volume UGIB → suspect peptic ulcer or varices.
Severe pain + bleed → consider perforation or malignancy.
Melaena vs iron tablets → melaena = black, tarry, sticky, offensive smell.
Always correct coagulopathy before scope.
Varices → always combine vasopressin analogue + antibiotics.

📖 References

NICE UGIB Pathway
BSG/RCP Joint UGIB Guidance

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Upper Gastrointestinal Bleed