Upper Gastrointestinal Bleeding Approach
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Direct answer
Upper gastrointestinal bleeding is bleeding proximal to the ligament of Treitz, and the first decision is risk stratification with the Glasgow-Blatchford score, where a score of 0 or 1 identifies patients who may be managed as outpatients. Resuscitation with blood and crystalloid comes first, followed by endoscopy within about 24 hours of presentation for most patients. Peptic ulcer and oesophageal or gastric varices are the commonest causes.
What you must remember
- Glasgow-Blatchford score: scores blood urea, haemoglobin, systolic pressure, pulse, melaena, syncope, hepatic disease and cardiac failure; a score of 0 or 1 suggests outpatient care.
- Resuscitation: two large-bore cannulas, crossmatched blood and a restrictive transfusion threshold of about 7 g/dL in most patients, rising to about 8 g/dL in cardiovascular disease.
- Endoscopy timing: within about 24 hours of resuscitation for most patients, within 12 hours when varices are suspected, and earlier when unstable.
- Varices: suspected variceal bleeding is treated with a vasoactive drug such as octreotide or terlipressin, antibiotic prophylaxis such as ceftriaxone, and band ligation at endoscopy.
- Forrest classification: active bleeding, a non-bleeding visible vessel and an adherent clot are high-risk stigmata that need endoscopic therapy.
- PPI use: an intravenous proton pump inhibitor is commonly given before endoscopy, and high-dose therapy continues after endoscopic treatment of high-risk ulcers.
- Tranexamic acid: a large trial in gastrointestinal bleeding did not reduce mortality, so it is not a routine adjunct.
Two very different bleeds
Two men with upper gastrointestinal bleeding need different first drugs and different endoscopic treatment, as the table shows, and both were scored before endoscopy.
| Feature | 55-year-old man with alcohol-related cirrhosis | 40-year-old man on daily naproxen |
|---|---|---|
| Presentation | Haematemesis, blood pressure 90/60 mmHg, pulse 120 per minute | Melaena, normal blood pressure, haemoglobin 11 g/dL |
| Risk and resuscitation | Glasgow-Blatchford score high; two cannulas and crossmatched blood, with transfusion kept restrained to avoid raising portal pressure | Score not low enough for outpatient care, so he is admitted |
| First drug | Octreotide or terlipressin with ceftriaxone, started without waiting for endoscopy | Intravenous proton pump inhibitor |
| Endoscopy | Within 12 hours: bleeding oesophageal varices, secured by band ligation | Within a day: bleeding duodenal ulcer treated with epinephrine injection and clips |
Both cases show that the cause, and the presence of cirrhosis, decide the first drug as well as the endoscopic therapy. Haemodynamic status sets the urgency in each case, so the first hour of care is not the same for both.
Where the exam tries to catch you
Upper gastrointestinal bleeding questions hinge on a few traps.
- Trap: treating haematemesis in a cirrhotic as a peptic ulcer Correct: varices are the default until proven otherwise, and the wrong drug or over-transfusion can worsen portal pressure.
- Trap: treating very early endoscopy as the standard Correct: endoscopy within a few hours has not consistently improved outcomes, so the answer is usually within 24 hours after resuscitation.
- Trap: dismissing haematochezia as a colonic cause when the patient is unstable Correct: haematochezia with haemodynamic instability can be a brisk upper gastrointestinal bleed, so candidates must think beyond the colon.
- Trap: confusing the Glasgow-Blatchford and Rockall scores Correct: Glasgow-Blatchford is used before endoscopy, while Rockall uses endoscopic findings.
In India, NSAIDs and steroids are common causes of peptic bleeding, so over-the-counter analgesic use should shape the differential.
Frequently asked questions
What does a Glasgow-Blatchford score of 0 or 1 mean?
A Glasgow-Blatchford score of 0 or 1 identifies upper gastrointestinal bleeding patients at very low risk, who may be managed as outpatients without urgent endoscopy. Higher scores predict the need for transfusion, endoscopic therapy or surgery and warrant admission.
When should endoscopy be performed in upper gastrointestinal bleeding?
Endoscopy for upper gastrointestinal bleeding is generally performed within about 24 hours of presentation once the patient is resuscitated, and earlier if haemodynamically unstable. Very early endoscopy within a few hours has not consistently improved outcomes, so it is not routinely required.
What haemoglobin threshold triggers transfusion in most upper gastrointestinal bleeding?
A restrictive transfusion threshold of about 7 g/dL is used in most patients with upper gastrointestinal bleeding, with a higher target of about 8 g/dL suggested for those with cardiovascular disease. Excess transfusion can raise portal pressure in variceal bleeding, so restraint matters there.
Which drugs are started before endoscopy for suspected variceal bleeding?
Vasoactive drugs such as octreotide or terlipressin are started before endoscopy for suspected variceal bleeding, together with antibiotic prophylaxis such as ceftriaxone. Band ligation is then performed at endoscopy to secure the bleeding varix.