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This guide provides an overview of the recognition and immediate management of upper gastrointestinal bleeding (UGIB) using an ABCDE approach.
The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working through the following steps:
- Airway
- Breathing
- Circulation
- Disability
- Exposure
Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment.
This guide has been created to assist students in preparing for emergency simulation sessions as part of their training, it is not intended to be relied upon for patient care.
Clinical features of upper gastrointestinal bleeding
Symptoms
Typical symptoms of upper gastrointestinal bleeding include:
- Haematemesis: typically coffee-ground like in appearance due to the presence of partially digested blood.
- Altered bowel habit: patients may describe dark tarry stools or fresh rectal bleeding.
- Abdominal pain: typically epigastric in location, but can be diffuse.
- Pre-syncope/syncope: due to hypovolaemia and secondary cerebral hypoperfusion.
Clinical signs
Typical clinical signs of upper gastrointestinal bleeding include:
- Tachycardia
- Hypotension
- Abdominal tenderness
- Malaena: black, tarry stools caused by the presence of digested blood.
- Haematochezia: the passage of fresh red blood per rectum, which can occur in the context of profuse upper gastrointestinal haemorrhage due to rapid transit of blood through the gastrointestinal tract.
Tips before you begin
General tips for applying an ABCDE approach in an emergency setting include:
- Treat all problems as you discover them.
- Re-assess regularly and after every intervention to monitor a patient’s response to treatment.
- Make use of the team around you by delegating tasks where appropriate.
- All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
- Clearly communicate how often would you like the patient’s observations relayed to you by other staff members.
- If you require senior input, call for help early using an appropriate SBARR handover structure.
- Review results as they become available (e.g. laboratory investigations).
- Make use of your local guidelines and algorithms in managing specific scenarios (e.g. acute asthma).
- Any medications or fluids will need to be prescribed at the time (in some cases you may be able to delegate this to another member of staff).
- Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical assessment, investigations and interventions.
Initial steps
Acute scenarios typically begin with a brief handover from a member of the nursing staff including the patient’s name, age, background and the reason the review has been requested.
You may be asked to review a patient with UGIB due to tachycardia, hypotension, malaena and/or haematemesis.
Introduction
Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.
Interaction
Introduce yourself to the patient including your name and role.
Ask how the patient is feeling as this may provide some useful information about their current symptoms.
Preparation
Make sure the patient’s notes, observation chart and prescription chart are easily accessible.
Ask for another clinical member of staff to assist you if possible.
If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines.
Airway
Clinical assessment
Can the patient talk?
Yes: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.
No:
- Look for signs of airway compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
- Open the mouth and inspect: look for anything obstructing the airway such as secretions or a foreign object.
Interventions
Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the emergency medical team (often referred to as the ‘crash team’). In the meantime, you can perform some basic airway manoeuvres to help maintain the airway whilst awaiting senior input.
Head-tilt chin-lift manoeuvre
Open the patient’s airway using a head-tilt chin-lift manoeuvre:
1. Place one hand on the patient’s forehead and the other under the chin.
2. Tilt the forehead back whilst lifting the chin forwards to extend the neck.
3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a finger sweep or suction to remove it.
Jaw thrust
If the patient is suspected to have suffered significant trauma with potential spinal involvement, perform a jaw-thrust rather than a head-tilt chin-lift manoeuvre:
1. Identify the angle of the mandible.
2. With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible.
3. Using your thumbs, slightly open the mouth by downward displacement of the chin.
Oropharyngeal airway (Guedel)
Airway adjuncts are often helpful and in some cases essential to maintain a patient’s airway. They should be used in conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.
An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may induce gagging and aspiration.
To insert an oropharyngeal airway:
1. Open the patient’s mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is present, attempt removal using suction.
2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction.
3. Advance the airway until it lies within the pharynx.
4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and feeling for signs of breathing.
Nasopharyngeal airway (NPA)
A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the NPA.
To insert a nasopharyngeal airway:
1. Check the patency of the patient’s right nostril and if required (depending on the model of NPA) insert a safety pin through the flange of the NPA.
2. Lubricate the NPA.
3. Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action.
4. If any obstruction is encountered, remove the tube and try the left nostril.
Other interventions
If the patient has clinical signs of anaphylaxis (e.g. angioedema, rash) commence appropriate treatment as discussed in our anaphylaxis guide.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Breathing
Clinical assessment
Observations
Review the patient’s respiratory rate:
- A normal respiratory rate is between 12-20 breaths per minute.
- Tachypnoea may indicate significant blood loss (>1500ml) or aspiration pneumonia.
Review the patient’s oxygen saturation (SpO2):
- A normal SpO2 range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk of CO2 retention.
- Hypoxaemia may occur secondary to aspiration pneumonia.
Auscultation
Auscultate the chest to screen for evidence of other respiratory pathology (e.g. coarse crackles may be present if the patient has developed aspiration pneumonia or pulmonary oedema secondary to fluid resuscitation).
Investigations and procedures
Arterial blood gas
Take an ABG if indicated (e.g. low SpO2) to quantify the degree of hypoxia.
Chest X-ray
A chest X-ray may be indicated if abnormalities are noted on auscultation (e.g. reduced air entry, coarse crackles) to screen for evidence of aspiration pneumonia. A chest X-ray should not delay the emergency management of UGIB.
See our CXR interpretation guide for more details.
Interventions
Oxygen
Administer oxygen if the patient has a low SpO2. This typically involves the use of a non-rebreathe mask with an oxygen flow rate of 15L. If the patient has COPD and a history of CO2 retention you should switch to a venturi mask as soon as possible and titrate oxygen appropriately.
If the patient is conscious, sit them upright as this can also help with oxygenation.
Adequately oxygenating the patient is important, however, be aware of the risks of aspiration if the patient vomits whilst wearing an oxygen mask.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Circulation
Clinical assessment
Pulse
Assess the patient’s pulse:
- Tachycardia is an early sign of volume depletion in the context of UGIB.
- The patient’s pulse may feel thready secondary to hypovolaemia.
Blood pressure
Assess the patient’s blood pressure:
- Patients with UGIB don’t typically develop hypotension until there has been significant blood loss (i.e. 1500-2000 mls).
Fluid balance assessment
Calculate the patient’s fluid balance:
- Calculate the patient’s current fluid balance using their fluid balance chart (e.g. oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts.
- Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult.
- Urine output is maintained until there has been significant blood loss (e.g. 1500-2000 mls).
Inspection
Inspect the patient from the end of the bed and note evidence of pallor indicative of anaemia.
Capillary refill time
Assess the patient’s capillary refill time (CRT):
- In the context of UGIB, the CRT may be prolonged (>2 seconds) both peripherally and centrally.
- The patient’s peripheries may also feel cool secondary to hypovolaemia and peripheral vasoconstriction.
Abdominal examination
Perform a brief abdominal examination which may reveal:
- Ascites secondary to cirrhotic liver disease.
- Abdominal tenderness (e.g. duodenal ulcer).
Investigations and procedures
Intravenous cannulation
Insert two large-bore cannulae (14-16G) and take blood tests as discussed below.
Adequate intravenous access is essential in the context of upper gastrointestinal bleeding as patients can rapidly deteriorate with haemodynamic instability which will then require large volumes of fluid and blood to be transfused.
Blood tests
Collect blood tests after cannulating the patient including:
- FBC: to assess the degree of anaemia to guide transfusion.
- U&Es: raised urea occurs in the context of UGIB due to digestion and absorption of blood proteins.
- Group and crossmatch: to confirm the patient’s blood group and request blood products.
- LFTs: to screen for evidence of liver disease (e.g. cirrhosis).
- Coagulation screen: to screen for coagulopathy and inform resuscitation efforts.
Interventions
Strict fluid balance
If not already in place, ask for a strict fluid balance to carefully monitor the patient’s fluid status to inform ongoing resuscitation efforts.
Aim for a urine output of greater than 30mls an hour.
Intravenous fluid resuscitation and blood transfusion
Fluid resuscitation
Hypovolaemic patients require fluid resuscitation:
- Administer a 500ml bolus of Hartmann’s solution or 0.9% sodium chloride (warmed if available) over 15 mins.
- Administer 250ml boluses in patients at increased risk of fluid overload (e.g. heart failure).
After each fluid bolus, reassess for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP).
Repeat administration of fluid boluses up to four times (e.g. 2000ml or 1000ml in patients at increased risk of fluid overload), reassessing the patient each time.
If the patient is losing significant volumes of blood, fluid replacement alone is inadequate and blood transfusion needs to be arranged (see below).
Seek senior input if the patient has a negative response (e.g. increased chest crackles) or if the patient isn’t responding adequately to repeated boluses (i.e. persistent hypotension).
See our fluid prescribing guide for more details on resuscitation fluids.
Blood transfusion
Blood transfusion should be guided by haemoglobin levels and the estimated volume of blood lost.
Base decisions on blood transfusion on the full clinical picture, recognising that over-transfusion may be as damaging as under-transfusion.
In the context of acute haemorrhage, O-negative blood may need to be administered if there is not adequate time for matching. This would, of course, be a senior-led decision.
Platelets
Patients with pre-existing liver disease may have low platelets due to portal hypertension and splenomegaly.
Platelets should be offered to patients who are actively bleeding with a platelet count of <50 x109/L.
Fresh frozen plasma and cryoprecipitate
Offer fresh frozen plasma to patients who are actively bleeding and have a prothrombin time or activated partial thromboplastin time greater than 1.5 times normal.
If a patient’s fibrinogen level remains less than 1.5 g/litre despite fresh frozen plasma use, offer cryoprecipitate as well.
This should be a consultant-led decision with haematology input.
Prothrombin complex
Offer prothrombin complex concentrate to patients taking warfarin who are actively bleeding.
This should be a consultant-led decision with haematology input.
Terlipressin
Terlipressin causes vasoconstriction of the splenic artery, reducing blood pressure in the portal system. It is recommended for use in all patients with suspected variceal bleeding at presentation. It should be stopped once definitive haemostasis has been achieved. ²
This should be a consultant-led decision.
Prophylactic antibiotic therapy
Offer prophylactic antibiotic therapy at presentation to patients with suspected or confirmed variceal bleeding.
The recommended antibiotic treatment is Ciprofloxacin 1g once daily for seven days.
Endoscopy
Endoscopy should be performed on all unstable patients with severe UGIB immediately after resuscitation. It should be performed within 24 hours of admission for all other patients with UGIB. This allows diagnostic confirmation and the opportunity to treat any bleeding sites.²
It’s essential to get input from an experienced gastroenterologist and anaesthetist early.
Proton pump inhibitor (PPI)
Proton pump inhibitors (PPIs) reduce the amount of acid produced by the stomach. High concentrations of acid increase the probability of re-bleeding due to decreased clot stability and therefore PPIs can be used to reduce this risk.
NICE advises that acid-suppression drugs (proton pump inhibitors or H2-receptor antagonists) should not be offered to patients before endoscopy with suspected non-variceal upper gastrointestinal bleeding.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Disability
Clinical assessment
Consciousness
In the context of UGIB, a patient’s consciousness level may be reduced secondary to hypotension or hepatic encephalopathy.
Assess the patient’s level of consciousness using the AVPU scale:
- Alert: the patient is fully alert, although not necessarily orientated.
- Verbal: the patient makes some kind of response when you talk to them (e.g. words, grunt).
- Pain: the patient responds to a painful stimulus (e.g. supraorbital pressure).
- Unresponsive: the patient does not show evidence of any eye, voice or motor responses to pain.
If a more detailed assessment of the patient’s level of consciousness is required, use the Glasgow Coma Scale (GCS).
Pupils
Assess the patient’s pupils:
- Inspect the size and symmetry of the patient’s pupils
- Assess direct and consensual pupillary responses
Drug chart review
Review the patient’s drug chart for medications which may cause a reduced level of consciousness (e.g. opioids, sedatives, anxiolytics, insulin, oral hypoglycaemic medications).
Investigations and procedures
Blood glucose and ketones
Measure the patient’s capillary blood glucose level to screen for causes of a reduced level of consciousness (e.g. hypoglycaemia or hyperglycaemia).
A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).
The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.
Hypoglycaemia is defined as a plasma glucose of less than 3.0 mmol/l. In hospitalised patients, a blood glucose ≤4.0 mmol/L should be treated if the patient is symptomatic.1
See our blood glucose measurement guide for more details.
Imaging
Request a CT head if intracranial pathology is suspected after discussion with a senior.
See our guide on interpreting a CT head for more details.
Interventions
Maintain the airway
Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient’s airway.
Maintain the patient’s airway as explained in the airway section of this guide.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Exposure
It may be necessary to expose the patient during your assessment: remember to prioritise patient dignity and conservation of body heat.
Clinical assessment
Inspection
Inspect the patient for stigmata of chronic liver disease and/or coagulopathy:
- Bruising
- Petechiae (e.g. thrombocytopenia)
- Spider naevi
- Caput medusae
- Ascites
- Evidence of trauma and bleeding from other sites
- Peripheral oedema
Temperature
Measure the patient’s temperature:
- If fever is present, make sure to consider co-existing infection.
Rectal examination
Perform a rectal examination to assess for evidence of gastrointestinal bleeding (e.g. malaena).
Interventions
Catheterisation
Catheterise the patient to closely monitor urine output to guide fluid resuscitation and need for escalation.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Reassess ABCDE
Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.
Deterioration should be recognised quickly and acted upon immediately.
Seek senior help if the patient shows no signs of improvement or if you have any concerns.
Support
You should have another member of the clinical team aiding you in your ABCDE assessment, such a nurse, who can perform observations, take samples to the lab and catheterise if appropriate.
You may need further help or advice from a senior staff member and you should not delay seeking help if you have concerns about your patient.
Use an effective SBARR handover to communicate the key information effectively to other medical staff.
Risk scoring systems
Blatchford score
The Blatchford score is calculated prior to endoscopy and is based on simple clinical and laboratory parameters. Its principal use is to identify low-risk patients who do not require any intervention (blood transfusion, endoscopic therapy, surgery). Approximately 20% of patients presenting with upper gastrointestinal haemorrhage have a Blatchford score of 0. Such patients can largely be managed safely in the community, as the mortality in this group is nil.³
Rockall score
It is important to identify those patients who are at risk of ongoing bleeding and death. The Rockall scoring system is used for risk categorisation based on simple clinical parameters. Rockall scores can be calculated both before and after endoscopy, but the post endoscopy Rockall score provides a more accurate risk assessment. It provides independent risk factors which have been shown to accurately predict the risk of rebleeding and mortality.³
With increasing age, there is an increased risk of death: ³
- Mortality in those aged below 40 is negligible.
- Mortality increases to 30% in those aged over 90.
- Patients who have evidence of active bleeding and signs of shock have an 80% risk of death.
- Those with a non-bleeding visible vessel at endoscopy have a 50% chance of re-bleeding.
Next steps
Well done, you’ve now stabilised the patient and they’re doing much better. There are just a few more things to do…
Take a history
Revisit history taking to explore relevant medical history. If the patient is confused you might be able to get a collateral history from staff or family members as appropriate.
See our history taking guides for more details.
Review
Review the patient’s notes, charts and recent investigation results.
Review the patient’s current medications and check any regular medications are prescribed appropriately.
Document
Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response.
See our documentation guides for more details.
Discuss
Discuss the patient’s current clinical condition with a senior clinician using an SBARR style handover.
Questions which may need to be considered include:
- Are any further assessments or interventions required?
- Does the patient need a referral to HDU/ICU?
- Does the patient need reviewing by a specialist?
- Should any changes be made to the current management of their underlying condition(s)?
Handover
The next team of doctors on shift should be made aware of any patient in their department who has recently deteriorated.
References
- Baskett, PJF. ABC of major trauma. Management of Hypovolaemic Shock. BMJ 1990; 300 1453-1457.
- NICE. Acute Upper Gastrointestinal Bleeding Management. (Updated 2016). Available from: [LINK].
- HJ Fellows & HR Dalton. Management of Acute Upper Gastrointestinal Haemorrhage. ICU. Published in 2010.
