🩺 Upper GI Bleeding

Upper Gastrointestinal Bleeding (UGIB) refers to bleeding originating proximal to the ligament of Treitz. It is a medical emergency with a significant mortality rate, particularly in the elderly and those with co-morbidities. Presentations range from occult bleeding to life-threatening exsanguination. Peptic ulcer disease remains the most common cause, but variceal bleeding associated with portal hypertension carries the highest risk of immediate death and requires specific management strategies.

Establish the volume and nature of the bleeding: haematemesis (bright red or 'coffee grounds') and melaena (tarry, offensive stool) are characteristic. Distinguish between haematemesis and haemoptysis (coughed up blood). Ask about previous episodes, alcohol intake, and use of ulcerogenic medications such as NSAIDs, aspirin, or anticoagulants. A history of forceful retching prior to haematemesis suggests a Mallory-Weiss tear, while weight loss and dysphagia point towards gastric or oesophageal malignancy.

Assessment begins with haemodynamic stability: look for tachycardia, hypotension, and cool peripheries signifying hypovolaemic shock. Check for stigmata of chronic liver disease (spider naevi, palmar erythema, ascites) which may point towards varices. A digital rectal examination is mandatory to confirm melaena and rule out lower GI sources. Abdominal palpation may reveal epigastric tenderness (ulcers) or masses (malignancy). Assess for signs of encephalopathy in patients with suspected portal hypertension.

Peptic Ulcer Disease (duodenal or gastric), Oesophageal Varices, Mallory-Weiss Tear, Gastritis/Erosive Oesophagitis, Gastric Malignancy, Dieulafoy Lesion.

Syncope, hypotension (systolic <90 mmHg), massive haematemesis, tachycardia, and failure to respond to initial fluid resuscitation.

Full blood count (haemoglobin and platelets), U&Es (urea), LFTs, and coagulation profile (PT/INR) are essential. Cross-match (usually 2-4 units) is vital if the patient is unstable. Oesophagogastroduodenoscopy (OGD) is both the definitive diagnostic and therapeutic tool; the timing (immediate vs. within 24 hours) depends on the Rockall Score and clinical stability. Chest X-ray should be performed if perforation is suspected (PUD). All patients should have their observations monitored frequently via a NEWS2 chart.

The Blatchford Score should be calculated upon initial presentation to identify 'low-risk' patients suitable for outpatient management. A high urea-to-creatinine ratio is a classic biochemical marker of a significant upper GI bleed due to the digestion of blood proteins. In patients with known liver disease, assume a variceal cause and initiate prophylactic antibiotics and vasopressors early. Never wait for an endoscopy to begin resuscitation in a haemodynamically unstable patient.

Management follows the NICE CG141 guidelines. Students must understand the 'restrictive' transfusion strategy (aiming for Hb 70-80g/L unless massive haemorrhage or significant cardiac history). Be familiar with the Rockall and Glasgow-Blatchford scoring systems. Recognise that IV Proton Pump Inhibitor (PPI) therapy should only be given *after* endoscopy for non-variceal bleeds, not before.