TABLE OF CONTENTS
KEY
🔍 | Deep Dive |
📌 | Clinical Application |
🔸 | Weak Evidence |
🔹 | Strong Evidence |
📑 | Evidence summaries |
✅ | Recommended treatment |
⚠️ | Critical Information |
💡 | Extra Reading |
❗ | Caveats |
Vitals are normal. The patient looks fine.
And yet — you still admit.
Because: “It’s a GI bleed… anything can happen.”
We’ve all said it. But let’s be honest —is that actually a good reason?
Let’s break it down.
What is Upper GI Bleed?
Upper gastrointestinal haemorrhage refers to bleeding originating proximal to the ligament of Treitz — typically from the oesophagus, stomach, or duodenum.
The ligament of Treitz is the suspensory muscle of the duodenum that connects it to the diaphragm.
The most common causes include:
- Peptic ulcer disease (PUD) — accounting for up to 67% of cases
- Variceal bleeding — especially in patients with liver disease
- Mallory–Weiss tears
- Aorto-enteric fistula — rare but catastrophic, often presenting with massive, rapid bleeding
Why Do We Care?
- One of the most common GI causes of hospitalisation
- Mortality ~ 10%
- Hypotension (SBP <90 mmHg) → strongly associated with mortality
- Hematemesis → worse outcomes than melena
Variceal Bleeds — A Different Beast
Even though variceal bleeds are relatively less common, they:
- Are high-pressure systems
- Have high rebleeding rates (up to 30%)
- Carry a significant mortality
These are high-risk from the start
The Diagnostic Challenge
Presentation is not always obvious.
- Hematemesis (~50%) and melena (~70%) are easier to recognise
- But patients may also present with:
- Syncope
- Dizziness
- Isolated tachycardia
And to confuse things further, Brisk UGIB can present as hematochezia
The Real ED Challenge
The problem is not identifying UGIB.
The real challenge is: Risk stratification and disposition
Step 1: Is the Patient Hemodynamically Unstable?
This is the first and most important decision point.
🔹BSG guidelines recommend that patients with acute UGIB and ongoing hemodynamic instability be referred for critical care review
If the patient is unstable, the decision is already made.
If NOT unstable → Ask the next question
Could this be a variceal bleed?
If yes:
🔸Strongly consider ICU (Baveno VII recommends intensive or intermediate care)
Let’s take a few moments to discuss the “ Resuscitation Principles”
- Airway
Indications for prophylactic intubation (ESGE/ Baveno VII)
- Severe haematemesis
- Agitation
- Inability to protect the airway.
- Altered consciousness
- Actively vomiting blood.
- Patients unable to tolerate endoscopy under conscious sedation
- Breathing
- Supplemental oxygen should be administered to achieve target saturations.
- Closely observe for aspiration
- Circulation
- Volume Replacement
- Blood Transfusion Strategy
- Higher targets only if:
- Ischemic heart disease or
- Significant comorbidities
🔹All major guidelines agree on one thing: Restore perfusion first with crytalloid bolus (ESGE / Baveno VII / BSG)
🔹This is one of the most consistent recommendations across guidelines: Restrictive transfusion is preferred
Target Hb: 7–9 g/dL (ESGE) / 7–8 g/dL (Baveno VII)
Overtransfusion can:
- Increase portal pressure
- Worsening bleeding (especially variceal)
- Other considerations
- Proton Pump Inhibitors (PPI)
- NICE → does not recommend routine pre-endoscopy PPI
- Antiplatelets & Anticoagulants
- Continue aspirin (secondary prevention) - If at all interrupted, start within 3-5 days
- Hold warfarin / DOACs initially
- P2Y12 inhibitors → case-by-case (especially with stents → discuss with cardiology)
- Timing of Endoscopy
- Unstable → immediate after resuscitation (NICE)
- Adjuncts and Early Interventions
- Consistently recommended across guidelines
- Improves visualization
- Reduces repeat endoscopy and transfusion
- Recommended in severe/ongoing bleeding
- Not routinely recommended (ESGE)
Guidelines differ:
🔹 ESGE → suggests high-dose IV PPI before endoscopy
Do not delay endoscopy for PPI infusion
🔹 All patients → within 24 hours (ESGE)
Erythromycin (pre-endoscopy)
Single dose, 250 mg given 30 – 120 minutes before upper gastrointestinal [GI] endoscopy
NG Tube
- Additional considerations in suspected variceal bleed (Baveno VII)
- Start early:
- Vasoactive agents: Terlipressin/somatostatin/octreotide
- Antibiotics: Ceftriaxone
- Correcting Coagulation
- FFP → Not recommended
- It may not correct coagulopathy and worsen volume overload, worsening portal hypertension
- Offer only if (NICE)
- Fibrinogen level of <1 g/L
- a prothrombin time (international normalised ratio) or activated partial thromboplastin time >1.5 times normal
- Tranexamic acid / rFVIIa → not recommended
- Platelets → only if actively bleeding and <50 × 10⁹/L (NICE Guidelines)
- Reduce portal pressure
- Prevent infection
- INR/PT do not reflect the true coagulation status
- It is important to focus on reducing portal hypertension rather than correcting INR
These patients are automatically high-risk
Why?
Step 2: Is It Truly an Upper GI Bleed?
Diagnosis is not always straightforward, but there are a few clues that can help
Clues in history -
- Known liver disease
- Any other symptoms of liver disease, like ascites and encephalopathy
- NSAID use (↑ risk ~4x)
- Alcohol use
- Prior PUD or H. pylori
- Recent vomiting (Mallory–Weiss)
Clues in the examination
- PR exam to confirm melena
Be cautious of imitators:
- Iron
- Bismuth
- Black foods
- True melena is jet black, tarry and foul-smelling
Remember this nuance
- UGIB → can present as hematochezia
- LGIB → can present as melena
Helpful Adjunct
- BUN:Creatinine >30 → suggests UGIB
Faecal Occult Blood Test (FOBT)
- No role in acute ED decision-making
- The American Gastroenterological Association say that the only indication for FOBT is in colorectal cancer screening.
- It has poor sensitivity (~25%)
- An intermittent GI bleed or a very acute one that has not had sufficient time to pass through the GI tract may not produce a positive FOBT, and a GI bleed cannot be ruled out based on a single negative result.
- High false positives
- Foods: Animal-derived heme, high eroxidase foods (e.g. broccoli, cauliflower, cantaloupe, carrots, squash), food dye additives (red, blue, yellow)
- Medications: Activated charcoal, Pepto-Bismol, simethicone, N-acetylcysteine
- Iatrogenic: Topical povidone-iodine solution (often used when inserting a Foley catheter)
- Extra-intestinal sources: Epistaxis, hemoptysis (3)
Many things can cause false positives
Step 3: Risk Stratification
Common pre-endoscopy scores:
- Glasgow Blatchford (GBS)
- Rockall (Pre-endoscopy)
- AIMS65
- ABC (age, blood tests, co-morbidities) - Used to predict 30-day mortality.
Glasgow Blatchford Score
Risk Factor at Presentation | Threshold | Score |
BUN (mg/dL) | <18.2 | 0 |
ㅤ | 18.2-22.3 | +2 |
ㅤ | 22.4-28 | +3 |
ㅤ | 28-70 | +4 |
ㅤ | >70 | +6 |
Hemoglobin (g/dL) for men | >13 | 0 |
ㅤ | 12-13 | +1 |
ㅤ | 10-12 | +3 |
ㅤ | <10 | +6 |
Hemoglobin (g/dL) for women | >12 | 0 |
ㅤ | 10-12 | +1 |
ㅤ | <10 | +6 |
Systolic blood pressure (mm Hg) | ≥110 | 0 |
ㅤ | 100–109 | +1 |
ㅤ | 90–99 | +2 |
ㅤ | <90 | +3 |
Pulse | ≥100 (per min) | +1 |
Melena | Present | +1 |
Presentation | Syncope | +2 |
Co-morbidity | Liver disease history | +2 |
ㅤ | Cardiac failure present | +2 |
GBS has the highest sensitivity for predicting intervention/death, but no score reliably predicts rebleeding or mortality
Interpreting GBS
- Low Risk: GBS 0–1 → consider discharge
Supported by: NICE / BSG / ESGE / ACG
In spite of this, ESGE (2021) does mention that discharged patients should be informed of the risk of recurrent bleeding and be advised to maintain contact with the discharging hospital.
- Moderate Risk : GBS ≥1 → Admit under appropriate speciality for endoscopy
BSG guidelines recommend admission under gastroenterology services.
- High Risk: Hemodynamic instability or Suspected variceal bleed → Consider ICU
Scores support decisions; they do not replace clinical judgment. Always remember, no scoring system is foolproof. So if you have a patient with a score of 0, but they appear unwell, don’t just discharge them just because of a score.
An additional marker: Lactate
A retrospective cohort study showed elevated lactate = worse prognosis in GI bleed [6]
- Lactate >4 mmol/L → ~6.4× increased mortality
- Each 1-point increase → ↑ mortality risk
What Matters
Before admitting a UGI bleed, ask three simple questions:
1️⃣ Is the patient hemodynamically unstable?
👉 If yes
→ Initiate aggressive resuscitation with fluids and blood transfusion.
→ Admit to ICU ( BSG guidelines)
2️⃣ Is this truly an upper GI bleed?
Clues in history -
- Known liver disease
- Any other symptoms of liver disease, like ascites and encephalopathy
- NSAID use (↑ risk ~4x)
- Alcohol use
- Prior PUD or H. pylori
- Recent vomiting (Mallory–Weiss)
Clues in the examination
- PR exam to confirm melena
Helpful Adjunct
- BUN:Creatinine >30 → suggests UGIB
👉 If yes → ask:
➡️ Could this be a variceal bleed?
👉 If yes → Admit to ICU / intermediate care (Baveno VII)
3️⃣ What is the Glasgow-Blatchford Score (GBS)?
Risk Factor at Presentaion | Threshold | Score |
BUN (mg/dL) | <18.2 | 0 |
ㅤ | 18.2-22.3 | +2 |
ㅤ | 22.4-28 | +3 |
ㅤ | 28-70 | +4 |
ㅤ | >70 | +6 |
Hemoglobin (g/dL) for men | >13 | 0 |
ㅤ | 12-13 | +1 |
ㅤ | 10-12 | +3 |
ㅤ | <10 | +6 |
Hemoglobin (g/dL) for women | >12 | 0 |
ㅤ | 10-12 | +1 |
ㅤ | <10 | +6 |
Systolic blood pressure (mm Hg) | ≥110 | 0 |
ㅤ | 100–109 | +1 |
ㅤ | 90–99 | +2 |
ㅤ | <90 | +3 |
Pulse | ≥100 (per min) | +1 |
Melena | Present | +1 |
Presentation | Syncope | +2 |
Co-morbidity | Liver disease history | +2 |
ㅤ | Cardiac failure present | +2 |
👉 GBS 0–1 (Low Risk)→ Consider discharge with outpatient follow-up
👉 GBS >1 (Moderate Risk)→ Admit for endoscopy under gastroenterology
Want to Read More?
- Siau, Keith, et al. "British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding." Frontline Gastroenterology 11.4 (2020): 311-323.
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