Upper Gastrointestinal Bleeding | Acute Management | ABCDE

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This guide provides an overview of theΒ recognitionΒ andΒ immediateΒ management of upper gastrointestinal bleeding (UGIB)Β using anΒ ABCDEΒ approach.

TheΒ ABCDEΒ 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 involvesΒ clinicalΒ assessment,Β investigationsΒ andΒ 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 emergencyΒ simulationΒ sessionsΒ as part of their training,Β 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

GeneralΒ tipsΒ for applying anΒ ABCDEΒ approachΒ in an emergency setting include:

  • Treat all problemsΒ as you discover them.
  • Re-assessΒ regularly and after every intervention to monitor a patient’s response to treatment.
  • Make use of the team around you byΒ delegating tasksΒ where appropriate.
  • All critically unwell patients should haveΒ continuous monitoringΒ equipment attached for accurateΒ observations.
  • Clearly communicate how often would you like the patient’s observations relayed to you by other staff members.
  • If you require senior input,Β call for help earlyΒ using an appropriateΒ SBARR handoverΒ structure.
  • Review resultsΒ as they become availableΒ (e.g.Β laboratory investigations).
  • Make use of your localΒ guidelinesΒ andΒ algorithmsΒ in managing specific scenarios (e.g.Β acute asthma).
  • AnyΒ medicationsΒ orΒ fluidsΒ will need to beΒ prescribedΒ at the time (in some cases you may be able to delegate this to another member of staff).
  • Your assessment and management should beΒ documentedΒ clearly in the notes, however, this shouldΒ not delayΒ initial clinical assessment, investigations and interventions.

Initial steps

Acute scenarios typically begin with aΒ briefΒ handoverΒ from a member of theΒ nursing staffΒ including theΒ patient’s name,Β age,Β backgroundΒ and theΒ reasonΒ theΒ reviewΒ has been requested.

You may be asked to review a patient with UGIB due to tachycardia, hypotension, malaena and/or haematemesis.

Introduction

IntroduceΒ yourselfΒ to whoever has requested a review of the patient andΒ listenΒ carefullyΒ to their handover.

Interaction

IntroduceΒ yourselfΒ to theΒ patientΒ including yourΒ nameΒ andΒ role.

AskΒ how the patient is feelingΒ as this may provide some useful information about their currentΒ symptoms.

Preparation

Make sure theΒ patient’sΒ notes,Β observationΒ chartΒ andΒ prescriptionΒ chartΒ are easily accessible.

Ask for anotherΒ clinicalΒ memberΒ ofΒ staffΒ toΒ assistΒ you if possible.

If the patient isΒ unconsciousΒ orΒ unresponsive, start theΒ basic life supportΒ (BLS)Β algorithmΒ 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 ofΒ airwayΒ compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
  • Open the mouthΒ andΒ inspect: look for anything obstructing the airway such as secretions or a foreign object.

Interventions

Regardless of the underlying cause of airway obstruction, seekΒ immediate expert supportΒ from an anaesthetist and the emergency medical team (often referred to as the β€˜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 airwayΒ using aΒ head-tiltΒ chin-lift manoeuvre:

1.Β Place one hand on the patient’s forehead and the other under the chin.

2.Β Tilt the forehead back whilst lifting the chin forwards to extend the neck.

3.Β Inspect theΒ airwayΒ for obviousΒ obstruction. If an obstruction is visible within the airway, use aΒ fingerΒ sweepΒ orΒ suctionΒ to remove it.

Jaw thrust

If the patient is suspected to have sufferedΒ significantΒ traumaΒ with potential spinal involvement, perform aΒ jaw-thrustΒ rather than a head-tilt chin-lift manoeuvre:

1.Β Identify the angle of the mandible.

2.Β With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible.

3.Β 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.

ToΒ insertΒ anΒ oropharyngealΒ airway:

1.Β 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.Β 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 180Β°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction.

3.Β Advance the airway until it lies within the pharynx.

4.Β 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.Β 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.Β Lubricate the NPA.

3.Β Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action.

4.Β If any obstruction is encountered, remove the tube and try the left nostril.

Other interventions

If the patient has clinical signs ofΒ anaphylaxisΒ (e.g. angioedema, rash) commence appropriate treatment as discussed in ourΒ anaphylaxis guide.

CPR

If the patientΒ loses consciousnessΒ and there areΒ no signs of lifeΒ on assessment, put out aΒ crash callΒ andΒ commence CPR.

Re-assessment

Make sure toΒ re-assessΒ the patient after anyΒ intervention.


Breathing

Clinical assessment

Observations

Review the patient’sΒ respiratoryΒ rate:

  • AΒ normalΒ respiratory rate is betweenΒ 12-20 breaths per minute.
  • Tachypnoea may indicate significant blood loss (>1500ml) or aspiration pneumonia.

Review the patient’sΒ oxygen saturationΒ (SpO2):

  • AΒ normal SpO2Β rangeΒ isΒ 94-98%Β in healthy individuals andΒ 88-92%Β in patients withΒ COPDΒ who are at high-risk ofΒ CO2Β 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 anΒ ABGΒ ifΒ indicatedΒ (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 ourΒ CXR interpretation guideΒ for more details.

Interventions

Oxygen

Administer oxygen if the patient has a low SpO2. This typically involves the use of aΒ non-rebreathe maskΒ with an oxygen flow rate ofΒ 15L. If the patient has COPD and a history of CO2Β retention you should switch to aΒ venturi maskΒ as soon as possible andΒ titrate oxygen appropriately.

If the patient is conscious, sit themΒ uprightΒ 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 patientΒ loses consciousnessΒ and there areΒ no signs of lifeΒ on assessment, put out aΒ crash callΒ andΒ commence CPR.

Re-assessment

Make sure toΒ re-assessΒ the patient after anyΒ intervention.


Circulation

Clinical assessment

Pulse

Assess the patient’sΒ 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’sΒ 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).
Classification of haemorrhagic shock
Classification of haemorrhagic shock 1

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

CollectΒ blood testsΒ 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 requireΒ fluidΒ 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,Β reassessΒ for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP).

Repeat administrationΒ of fluid boluses up toΒ four timesΒ (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 inputΒ 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 ourΒ fluid prescribing guideΒ for more details onΒ 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. Β It isΒ recommendedΒ for use in all patients with suspected variceal bleeding at presentation. It should be stopped once definitive haemostasis has been achieved. Β²

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. Β This allows diagnostic confirmation and the opportunity to treat any bleeding sites.Β²

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 patientΒ loses consciousnessΒ and there areΒ no signs of lifeΒ on assessment, put out aΒ crash callΒ andΒ commence CPR.

Re-assessment

Make sure toΒ re-assessΒ the patient after anyΒ 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’sΒ level of consciousnessΒ using theΒ 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 theΒ Glasgow Coma ScaleΒ (GCS).

Pupils

Assess the patient’sΒ pupils:

  • Inspect theΒ sizeΒ andΒ symmetryΒ of the patient’s pupils
  • AssessΒ directΒ andΒ consensualΒ pupillaryΒ responses

Drug chart review

Review the patient’sΒ drug chartΒ forΒ medicationsΒ which may cause aΒ reduced level of consciousnessΒ (e.g. opioids, sedatives, anxiolytics, insulin, oral hypoglycaemic medications).

Investigations and procedures

Blood glucose and ketones

Measure the patient’sΒ capillary blood glucoseΒ 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).

TheΒ normalΒ reference rangeΒ for fasting plasma glucose isΒ 4.0 – 5.8 mmol/l.

HypoglycaemiaΒ is defined as a plasma glucose ofΒ less thanΒ 3.0 mmol/l. InΒ hospitalised patients, a blood glucose ≀4.0 mmol/LΒ should be treated if the patient isΒ symptomatic.1

See ourΒ blood glucose measurementΒ guide for more details.

Imaging

Request aΒ CTΒ headΒ if intracranial pathology is suspected after discussion with a senior.

See our guide onΒ interpreting aΒ CT headΒ for more details.

Interventions

Maintain the airway

Alert aΒ seniorΒ immediately if you have any concerns about the consciousness level of a patient. A GCS ofΒ 8 or belowΒ warrantsΒ urgent expert helpΒ from anΒ anaesthetist. In the meantime, you shouldΒ re-assessΒ andΒ maintain the patient’s airway.

Maintain the patient’s airwayΒ as explained in the airway section of this guide.

CPR

If the patientΒ loses consciousnessΒ and there areΒ no signs of lifeΒ on assessment, put out aΒ crash callΒ andΒ commence CPR.

Re-assessment

Make sure toΒ re-assessΒ the patient after anyΒ intervention.


Exposure

It may be necessary toΒ exposeΒ the patient during your assessment: remember to prioritise patient dignity and conservation of body heat.Β 

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’sΒ 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

CatheteriseΒ the patient to closelyΒ monitor urine outputΒ to guide fluid resuscitation and need for escalation.

CPR

If the patientΒ loses consciousnessΒ and there areΒ no signs of lifeΒ on assessment, put out aΒ crash callΒ andΒ commence CPR.

Re-assessment

Make sure toΒ re-assessΒ the patient after anyΒ intervention.


Reassess ABCDE

Re-assessΒ the patient using theΒ ABCDE approachΒ to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.

DeteriorationΒ should be recognised quickly and acted upon immediately.

Seek senior helpΒ 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 shouldΒ not delay seeking help if you have concerns about your patient.

Use an effectiveΒ SBARR handoverΒ 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.Β³

Blatchford scoring system
Blatchford scoring system Β³
Β 

Rockall score

It is important to identify those patients who are at risk of ongoing bleeding and death. TheΒ Rockall scoring system is used for risk categorisationΒ based on simple clinical parameters. Rockall scores can be calculated both before andΒ after endoscopy, but the post endoscopy Rockall score provides a more accurate riskΒ assessment. It provides independent risk factors which have been shown to accurately predict the risk of rebleeding and mortality.Β³

With increasing age, there is an increased risk of death: Β³

  • 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.
Rockall scoring system
Rockall scoring system Β²

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 ourΒ history taking guidesΒ for more details.

Review

Review theΒ patient’s notes,Β chartsΒ andΒ recent investigation results.

Review the patient’sΒ current medicationsΒ and check any regular medications areΒ prescribed appropriately.

Document

ClearlyΒ document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response.

See ourΒ documentation guidesΒ for more details.

Discuss

Discuss the patient’s current clinical condition with aΒ seniorΒ clinicianΒ using anΒ SBARRΒ style handover.

QuestionsΒ which may need to be considered include:

  • Are any further assessments or interventions required?
  • Does the patient need a referral toΒ 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 beΒ made awareΒ of any patient in their department who hasΒ recently deteriorated.


References

  1. Baskett, PJF. ABC of major trauma. Management of Hypovolaemic Shock. BMJΒ  1990; 300 1453-1457.
  2. NICE. Acute Upper Gastrointestinal BleedingΒ Management. (Updated 2016). Available from: [LINK].
  3. HJ Fellows & HR Dalton.Β Management of Acute Upper Gastrointestinal Haemorrhage.Β ICU. Published in 2010.

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