Gastrointestinal Bleeding Management
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Direct answer
Upper gastrointestinal bleeding, defined proximal to the ligament of Treitz, presents with haematemesis and melaena and is managed by a fixed pathway: vigorous resuscitation with large-bore access, restrictive transfusion at a haemoglobin threshold of about 7 g/dL in stable patients, risk scoring with the Glasgow-Blatchford score, then endoscopy within 24 hours of presentation once stabilised. Endoscopic haemostasis with combined adrenaline injection plus a mechanical or thermal modality treats high-risk ulcers, stratified by the Forrest classification from a spurting artery to a clean base, followed by high-dose proton pump inhibitor infusion. Variceal bleeding adds terlipressin and prophylactic antibiotics with endoscopic band ligation, balloon tamponade as a temporising bridge, and transjugular intrahepatic portosystemic shunt or surgery for failures; massive lower gastrointestinal bleeding is investigated by colonoscopy, CT angiography or tagged red cell scanning depending on activity.
What you must remember
- Melaena can follow as little as 50–100 mL of upper bleeding, and haematochezia with instability suggests a brisk upper source; resuscitation precedes diagnosis, transfusing at a haemoglobin threshold of about 7 g/dL in stable patients.
- Glasgow-Blatchford score (haemoglobin, urea, pulse, systolic pressure, syncope, melaena, cardiac or liver disease) identifies patients for outpatient management at a score of 0–1; the Rockall score adds endoscopic findings to predict mortality.
- Endoscopy within 24 hours in stable patients and immediately after resuscitation in unstable active bleeders; intravenous erythromycin before endoscopy improves gastric views.
- Forrest classification of ulcer bleeding: Ia spurting, Ib oozing, IIa visible vessel, IIb adherent clot, IIc pigment spots, III clean base — rebleed risk falls from top to bottom.
- High-dose PPI after endoscopic haemostasis of high-risk ulcers is commonly given as 80 mg bolus followed by 8 mg per hour for 72 hours.
- Variceal pathway: terlipressin plus antibiotics such as ceftriaxone, endoscopic band ligation, balloon tamponade (Sengstaken-Blakemore or Minnesota) for no more than about 24 hours as a bridge to definitive therapy.
- Massive lower GI bleeding: CT angiography for active bleeding (detects around 0.5 mL/min), tagged red blood cell scintigraphy for slower intermittent bleeding (detects around 0.1 mL/min per classical teaching), with colonoscopy after preparation when stable.
Common confusion
The exam traps you into endoscoping an unstable patient. Endoscopy follows, not precedes, restoration of perfusion — except variceal bleeding after vasoactive drug cover, where early endoscopy within 12 hours is standard. A second confusion is treating a clean-based ulcer (Forrest III) with an infusion and repeat endoscopy: it needs no endoscopic therapy at all.
Exam-focused takeaway
Learn the pathway as a flow: resuscitate, score, scope, treat, re-treat. Score questions contrast Glasgow-Blatchford (pre-endoscopy, outpatient triage) with Rockall (mortality prediction). Forrest class matching (Ia spurting vessel) and the PPI regimen (80 mg bolus, 8 mg/h, 72 hours) are direct-recall marks. Variceal questions pair terlipressin with antibiotics and band ligation; the tamponade tube is a bridge, never therapy. For obscure recurrent bleeding, remember capsule endoscopy for the small bowel.
Frequently asked questions
How is an upper GI bleed defined and why does it matter?
Bleeding proximal to the ligament of Treitz; most such bleeds settle or are controlled endoscopically, so the pathway centres on resuscitation and endoscopy rather than urgent surgery.
Which score decides outpatient management of upper GI bleeding?
The Glasgow-Blatchford score, which uses only clinical and laboratory variables; a score of 0–1 identifies very low-risk patients suitable for outpatient endoscopy.
What do you do for an ulcer with a visible vessel?
Combined therapy — adrenaline injection plus clips or a thermal method — followed by high-dose proton pump inhibitor infusion, as visible vessels carry high rebleeding risk.
When is balloon tamponade used in variceal bleeding?
As a temporary bridge for uncontrolled bleeding despite pharmacotherapy and banding, for a maximum of about 24 hours, pending definitive transjugular intrahepatic portosystemic shunt or surgery.