Gastrointestinal Bleeding
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Direct answer
Haematemesis in an Indian emergency department is a race between resuscitation and endoscopy: two large-bore cannulae, crystalloid then blood, a restrictive transfusion trigger (typically haemoglobin around 7 g/dL, higher in cirrhosis with active bleeding), and upper gastrointestinal endoscopy within 24 hours — within 12 for variceal suspicion. Variceal bleeding gets terlipressin 2 mg intravenously every 4-6 hours plus antibiotic prophylaxis (ceftriaxone 1 g daily) before endoscopic band ligation; bleeding peptic ulcers are graded by the Forrest classification and treated endoscopically with epinephrine injection combined with a thermal or mechanical method, followed by a high-dose intravenous proton pump inhibitor (80 mg bolus, then 8 mg/hour for 72 hours). Lower gastrointestinal bleeding — fresh per rectum with a negative upper scope — localises by colonoscopy, with CT angiography for active massive bleeding and tagged red-cell scan for intermittent ooze.
What you must remember
- Causes, Indian pattern: oesophageal varices from cirrhosis and non-cirrhotic portal fibrosis are prominent in Indian series alongside peptic ulcer disease, which dominates Western statistics; Mallory-Weiss tears, gastric erosions and oesophagitis complete the upper list.
- Triage scores: Glasgow-Blatchford score (bloods plus blood pressure and pulse) identifies patients safe for outpatient endoscopy — a score of 0-1; the Rockall and full Glasgow-Blatchford scores predict mortality; variceal bleeding carries Child-Pugh weighting in counselling.
- Massive transfusion: activate a protocol at sustained haemodynamic instability, transfusing packed cells, fresh frozen plasma and platelets in balanced ratios rather than chasing numbers with cells alone; correct clinically significant coagulopathy, and watch potassium and calcium in rapid transfusion.
- Variceal bundle: vasoactive drug from admission (terlipressin 2 mg 4-6 hourly or octreotide infusion), empirical ceftriaxone 1 g daily for 5-7 days, endoscopic band ligation as first-line therapy, balloon tamponade (Sengstaken-Blakemore or Minnesota) only as a bridge of hours, and consideration of transjugular intrahepatic portosystemic shunt for uncontrolled bleeding.
- Ulcer therapy: for endoscopic high-risk stigmata — active spurting (Forrest Ia) or a visible vessel (IIa) — epinephrine injection must be combined with contact thermal coagulation, clips or both, because injection alone recurs; intravenous pantoprazole 80 mg bolus plus 8 mg/hour for 72 hours follows.
- Failure criteria: rebleeding with shock, continued transfusion needs, or a non-visible vessel that cannot be treated point to repeat endoscopy, then embolisation or surgery.
- Obscure and lower bleeding: after a negative upper endoscopy, colonoscopy first; massive active bleeding goes straight to CT angiography with embolisation; a positive tagged red-cell scan localises intermittent bleeding when other tests fail; in India, haemorrhoids and colorectal neoplasia head the lower-GI list, with massive bleeding most often diverticular in the elderly.
- Do not forget: aspirin and clopidogrel held when safe, Helicobacter pylori eradication after ulcer haemostasis, and a second look at the rectal examination — melena can precede haematemesis in slow upper bleeds.
A typical resuscitation-to-scope pathway
A 50-year-old man with known cirrhosis from hepatitis C vomits 400 mL of fresh blood; his pulse is 112, blood pressure 96/60, and he is drowsy. Ordered reasoning: protect the airway in an encephalopathic bleeder, two wide-bore cannulae, cross-match, start terlipressin 2 mg intravenously and ceftriaxone 1 g, restrict transfusion to a haemoglobin target of about 8 g/dL (over-transfusing a cirrhotic raises portal pressure), and move to endoscopy within 12 hours. Band ligation of oesophageal varices achieves haemostasis; a gastric varix would instead call for injection of cyanoacrylate glue. If bleeding continues despite two failed endoscopic attempts, the bridge is balloon tamponade while arranging a transjugular intrahepatic portosystemic shunt. Contrast the peptic ulcer stem: a 60-year-old on aspirin with melena and a clean-based ulcer at endoscopy needs no endoscopic therapy and no infusion protocol beyond oral proton pump inhibitor — risk stratification by stigmata, not reflex treatment, is the tested judgement.
Where students slip
The screen rewards three separations. Fresh haematemesis with known cirrhosis versus an elderly non-steroidal user: same resuscitation, different drugs — terlipressin and ceftriaxone for the varix, proton pump inhibitor infusion for the ulcer. Melena versus haematochezia: melaena means upper (above the ligament of Treitz, typically), while massive fresh rectal bleeding with haemodynamic compromise can still be upper — always pass the endoscope before the colonoscope in the unstable bleeder. Finally, injection monotherapy for a visible vessel is the classic wrong answer: epinephrine alone dissipates, and the standard is combination therapy with coagulation or clips.
Frequently asked questions
Within what time frame should upper gastrointestinal endoscopy be performed?
Within 24 hours of presentation for most upper gastrointestinal bleeding, and within about 12 hours where variceal bleeding is suspected, after initial resuscitation.
What drug therapy accompanies endoscopic band ligation for variceal bleeding?
Terlipressin 2 mg intravenously every 4-6 hours (or an octreotide infusion) plus antibiotic prophylaxis with ceftriaxone 1 g daily, both started at admission.
What does the Forrest classification guide?
It stratifies endoscopic stigmata of bleeding ulcers — from active spurting through visible vessel to clean base — and thereby dictates which lesions need combination endoscopic therapy and which need none.
What is the proton pump inhibitor regimen after endoscopic haemostasis?
High-dose intravenous therapy, classically a pantoprazole 80 mg bolus followed by 8 mg/hour infusion for 72 hours, then oral therapy with Helicobacter pylori eradication.
How is the source of obscure lower gastrointestinal bleeding localised?
Colonoscopy first if stable; CT angiography for active brisk bleeding with embolisation of the culprit vessel; tagged red blood cell scanning for intermittent bleeding, with capsule endoscopy for the obscure mid-gut.