9. Upper Gastrointestinal Bleed

📄 Definition

An upper GI bleed refers to bleeding originating proximal to the ligament of Treitz (i.e. from the oesophagus, stomach, or duodenum). It is a medical emergency that can present with haematemesis, melaena, or signs of shock.

🛡️ Causes (Mnemonic: GASTRIC)

  • Gastritis

  • Arteriovenous malformation

  • Stress ulcers (ICU, post-op, trauma)

  • Tumours (gastric or oesophageal cancer)

  • Ruptured varices (e.g. in cirrhosis)

  • Iatrogenic (e.g. post-endoscopy, NSAID use)

  • Common: peptic ulcer disease (most common overall)

📋 Clinical Features (Mnemonic: HOBBIT)

  • Haematemesis (fresh blood or coffee ground vomitus)

  • Orthostatic hypotension (postural drop)

  • Blood per rectum (melaena or rarely haematochezia if massive)

  • Breathlessness / tachypnoea

  • Iron-deficiency anaemia (chronic cases)

  • Tachycardia, pallor, and shock in severe bleeding

⚠️ Red Flags

  • Signs of shock: cold peripheries, confusion, systolic BP <100 mmHg

  • Active bleeding: haematemesis or continued melaena

  • Known liver disease or varices

  • Syncope or postural drop

  • Anticoagulant or antiplatelet use

🔬 Investigations (Initial and Diagnostic)

Initial (within A–E):

  • FBC – anaemia

  • U&Es – raised urea (blood digestion)

  • LFTs – liver disease or coagulopathy

  • Clotting screen – INR/PT

  • Group & save / crossmatch

  • ABG and lactate (if unwell)

Diagnostic:

  • OGD within 24 hours (or within 12 hours if haemodynamically unstable or varices suspected)

📉 Scoring Tools

ScoreUse
Glasgow-Blatchford Score (GBS)Pre-endoscopy risk stratification – outpatient vs admission
Rockall ScorePost-endoscopy – predicts re-bleed and mortality

Management (Mnemonic: ABCDE + STOP)

🔴 Acute Resuscitation (A–E approach)

  • Airway protection (risk of aspiration)

  • Breathing: oxygen as needed

  • Circulation: large-bore IV access, IV fluids, blood if required

  • Disability: assess consciousness, blood sugar

  • Exposure and monitor bleeding

🔒 Specific Therapies – STOP

  • Stop offending agents (NSAIDs, anticoagulants – per senior advice)

  • Terlipressin IV (if variceal bleed suspected)

  • OGD with banding/clipping/adrenaline injection as indicated

  • Proton Pump Inhibitor (e.g. omeprazole IV 80 mg bolus + infusion) if non-variceal ulcer suspected

For varices: combine terlipressin + IV antibiotics + band ligation

❗ Complications (Mnemonic: SHOCKED)

  • Shock (hypovolaemic)

  • Haemorrhage requiring transfusion

  • Ongoing bleeding or re-bleed

  • Coagulopathy

  • Kidney injury

  • Encephalopathy (in variceal bleeds)

  • Death (5–10% mortality)

Last updated in line with NICE NG184 (Acute upper gastrointestinal bleeding in over 16s: management)
Published: June 2023 • Last updated: June 2023
Last reviewed: July 2025
PASSMAP ensures all content is NICE-aligned and reviewed for Physician Associate Registration Assessment (PARA) success.

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