Acute Upper Gastrointestinal Bleeding

Acute upper gastrointestinal bleeding is haemorrhage from a source proximal to the ligament of Treitz, presenting as haematemesis, melaena or haemodynamic compromise.

• Peptic ulcer disease causes about 40 to 50 percent of cases, followed by varices, erosive gastritis and oesophagitis, Mallory-Weiss tear, malignancy, Dieulafoy lesion and angiodysplasia.
• Mortality is about 5 to 10 percent and is driven by age, comorbidity, shock, variceal source and rebleeding.
• Risk factors: NSAIDs and aspirin, anticoagulants, Helicobacter pylori, cirrhosis, alcohol, critical illness and chronic kidney disease.

Presentation depends on the rate and volume of blood loss.

• Haematemesis (fresh red or coffee ground), melaena, and haematochezia when bleeding is brisk (more than 1 L).
• Dizziness, syncope, palpitations, dyspnoea and angina from anaemia or hypovolaemia.
• Shock signs: pulse above 100 beats/min, systolic pressure below 100 mmHg, postural drop of 20 mmHg or more, cool peripheries, oliguria.
• Stigmata of chronic liver disease, epigastric tenderness, and a history of dyspepsia, NSAID use or vomiting before the bleed.
• Differential diagnosis: epistaxis or swallowed blood, haemoptysis, iron or bismuth causing black stool, brisk right-sided colonic or small bowel bleeding, food dyes.
• Complications: hypovolaemic shock, rebleeding, aspiration, myocardial ischaemia, acute kidney injury, hepatic encephalopathy in cirrhosis, transfusion reactions and death.

Assessment and resuscitation run together.

• Bloods: full blood count (haemoglobin may be normal early), group and crossmatch 2 to 4 units, urea (disproportionately raised relative to creatinine), creatinine, electrolytes, liver profile, INR, lactate, glucose. ECG and troponin in those over 60 or with cardiac disease.
• Risk stratification with a validated bleeding score decides outpatient versus admission.
• Upper endoscopy within 24 hours after resuscitation, and within 12 hours if varices are suspected or the patient is unstable.
• Ulcer high-risk stigmata: active spurting, oozing, visible vessel, adherent clot. A clean base or flat spot carries low rebleeding risk.
• CT angiography if endoscopy is non-diagnostic with ongoing bleeding.

Supportive

• Airway protection (intubate for massive haematemesis or reduced consciousness), oxygen, two large-bore cannulae, nil by mouth.
• Crystalloid 500 mL boluses to a systolic pressure of 100 mmHg and no more, avoiding over-resuscitation.
• Transfuse red cells to keep haemoglobin at 7 to 8 g/dL (target 8 to 9 g/dL with cardiovascular disease). Platelets if below 50 x 10^9/L with active bleeding. Fresh frozen plasma or prothrombin complex concentrate if INR above 1.5 with bleeding.
• Warfarin reversal: vitamin K 5 to 10 mg IV plus prothrombin complex concentrate 25 to 50 IU/kg.
• Stop NSAIDs, aspirin (restart early once haemostasis is secure if for secondary prevention) and anticoagulants.

Pharmacological

• Erythromycin 250 mg IV 30 to 120 minutes before endoscopy to clear the stomach.
• Pantoprazole 80 mg IV bolus then 8 mg/h infusion for 72 hours after endoscopic therapy of a high-risk ulcer, or 40 mg IV twice daily. Follow with oral pantoprazole or omeprazole 40 mg twice daily for 14 days then 40 mg daily.
• Suspected varices: terlipressin 2 mg IV every 4 hours for 2 to 5 days (or octreotide 50 microgram bolus then 50 microgram/h), plus ceftriaxone 1 g IV daily for up to 7 days.

Procedures

• Endoscopic therapy for high-risk ulcers: adrenaline 1 in 10,000 injection combined with a clip or thermal coagulation. Adrenaline alone is inadequate.
• Variceal bleeding: band ligation. Gastric variceal bleeding: cyanoacrylate injection.
• Rebleeding: repeat endoscopy once, then angiographic embolisation or surgery (oversewing with vagotomy or resection).

Special groups

• Cirrhosis: restrictive transfusion, antibiotics, lactulose 30 mL twice daily for encephalopathy prevention, and early transjugular portosystemic shunt for high-risk variceal bleeding.
• Test for H. pylori and eradicate if positive (omeprazole 20 mg, amoxicillin 1 g, clarithromycin 500 mg, each twice daily for 14 days, or a bismuth quadruple regimen where clarithromycin resistance is high).

Red flags: shock despite fluids, ongoing haematemesis, haemoglobin falling more than 2 g/dL, rebleeding within 72 hours, age above 70 years with comorbidity.

Follow-up: confirm eradication of H. pylori at least 4 weeks after treatment; repeat endoscopy at 6 to 8 weeks for gastric ulcers to exclude malignancy.