Acute GI Bleeding and Endoscopy
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Direct answer
Risk-stratify before you scope: a Glasgow-Blatchford score of 1 or less identifies patients with upper gastrointestinal bleeding who can be managed as outpatients, while haemodynamic instability drives two large-bore cannulae, restrictive transfusion to a haemoglobin target of 7 g/dL and endoscopy within 24 hours of resuscitation. Endoscopic haemostasis for peptic ulcer bleeding follows the Forrest classification — active spurting (Ia), oozing (Ib), non-bleeding visible vessel (IIa), adherent clot (IIb), flat pigmented spot (IIc) and clean base (III) — with combination therapy the rule: epinephrine injection alone is always paired with a mechanical or thermal modality because it alone halves nothing reliably. High-dose PPI (an 80 mg bolus then 8 mg/hour infusion for 72 hours) follows successful haemostasis of high-risk stigmata. Rebleeding is treated by repeat endoscopy before surgical or radiological rescue; lower gastrointestinal bleeding runs a parallel pathway of colonoscopy after purge, with CT angiography first if the patient is too unstable to prepare.
What you must remember
- Glasgow-Blatchford components: blood urea, haemoglobin, systolic pressure, pulse, syncope, melena, hepatic disease and cardiac failure — a score of 0–1 defines the outpatient-eligible group; the Rockall and post-endoscopy Rockall add age and endoscopic findings to predict mortality.
- Forrest-risk pairing: Forrest I and IIa need active combination haemostasis; IIb (adherent clot) warrants attempted clot removal and treatment of the underlying stigma; IIc and III need no endoscopic therapy — the classification is the answer key to "which lesion do you treat".
- Combination therapy rule: dilute epinephrine (1:10,000) injection achieves temporary vasoconstriction and must be followed by a definitive modality — haemoclips, bipolar electrocoagulation, or absolute alcohol — because injection alone leaves rebleeding rates unacceptably high.
- PPI pharmacology: after endoscopic control of high-risk lesions, an 80 mg intravenous bolus followed by an 8 mg/hour infusion for 72 hours, then high-dose oral therapy; pre-endoscopy PPI does not change outcomes and should not delay the procedure.
- Transfusion threshold: haemoglobin 7 g/dL in stable patients (8 g/dL tolerated in those with cardiovascular disease), packed cells titrated carefully in suspected variceal bleeding where over-transfusion is itself harmful.
- Variceal clock: suspected variceal haemorrhage gets vasoactive drugs and antibiotic prophylaxis from the emergency bay with endoscopy within 12 hours — a different clock from the 24-hour peptic window.
- Obscure bleeding algorithm: recurrent visible or iron-deficiency bleeding with negative bidirectional endoscopy goes to video capsule endoscopy first, then device-assisted enteroscopy directed by the capsule's lesion localisation; repeat upper endoscopy with a colonoscope looking for missed caecal or small-bowel-entrant lesions is a legitimate earlier step.
- Lower GI bleeding order: haemodynamic instability or ongoing brisk bleeding — CT angiography first, with radiological embolisation or surgery; stable patients — bowel purge then colonoscopy within 24 hours; massive rectal bleeding still deserves an upper endoscopy early, because a substantial minority of "lower" bleeds are upper in origin.
- Antithrombotic handling: continue aspirin for cardiovascular indications through the acute bleed wherever possible; hold other agents by renal and thrombotic context, resuming after haemostasis — and every ulcer bleed needs H pylori testing and eradication.
A worked night-shift case
A 68-year-old on low-dose aspirin presents with melaena and syncope; pulse 110, systolic 95, haemoglobin 8.4, urea 14. Blatchford well above the outpatient threshold, so resuscitate with crystalloid and crossmatch, hold the aspirin, and transfuse only if the haemoglobin falls below 7 or cardiac ischaemia appears. Endoscopy at 6 hours shows a duodenal ulcer with a visible vessel: haemoclips plus epinephrine injection, then an 80 mg esomeprazole bolus with an 8 mg/hour 72-hour infusion, aspirin resumed after haemostasis, and H pylori stool antigen sent (with eradication if positive). On day 3 he rebleeds with fresh melaena and a pulse of 120: repeat endoscopy is the mandated next step — re-treat the stigma, and only failure at the second attempt invokes angiographic embolisation or surgery. Had he arrived unstable with known cirrhosis, the clock would have shortened to 12 hours with terlipressin and ceftriaxone aboard, and the target lesion would have been a varix with bands rather than an ulcer with clips.
How the exam frames it
The examiner's levers are the numbers and the sequence: which score sends the patient home (Blatchford 0–1), which lesion needs treatment (Forrest), which drug timing (PPI after haemostasis, not before), which transfusion target (7 g/dL), and which step after rebleeding (repeat endoscopy, not straight to theatre). Distractors are built from single-modality epinephrine, from pre-endoscopy PPI infusions, and from transfusing to 10 g/dL. The Indian viva version asks who gets the 2 a.m. scope first — the answer is always the variceal bleeder and the unstable ulcer patient, in that order of clock-speed.
Frequently asked questions
Which score identifies patients suitable for outpatient management?
A Glasgow-Blatchford score of 0–1, based on urea, haemoglobin, vital signs and comorbidity, defines very-low-risk upper GI bleeding manageable without admission.
How does the Forrest classification direct endoscopic therapy?
Active bleeding and non-bleeding visible vessels (Forrest I, IIa) require combination haemostasis; adherent clots (IIb) warrant removal and treatment; flat spots and clean bases (IIc, III) need no endoscopic therapy.
Why is epinephrine injection never sufficient alone?
It provides only temporary tamponade and vasoconstriction, with high rebleeding rates unless combined with clips, contact thermal coagulation or another definitive modality.
What is the transfusion target in acute GI bleeding?
A restrictive haemoglobin target of 7 g/dL in stable patients (about 8 with cardiovascular disease), since liberal transfusion worsens outcomes and raises portal pressures.
What follows endoscopic haemostasis of a high-risk ulcer?
High-dose PPI — 80 mg bolus then 8 mg/hour for 72 hours — oral high-dose continuation, H pylori testing with eradication, and review of aspirin and antithrombotic therapy.