Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition that needs to be rapidly recognised and managed effectively, with the involvement of appropriate senior support. This guide gives an overview of the recognition and immediate management of upper gastrointestinal bleeding (using an ABCDE approach).
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
- Abdominal pain – may be epigastric or diffuse
- Haematemesis – vomiting of bright red blood
- Coffee-ground vomit – vomiting of black material (blood altered by gastric acid)
- Melaena – black tarry stools (digested blood)
- Haematochezia – passage of fresh blood per rectum (can occur in profuse upper gastrointestinal haemorrhage)
- Pre-syncope/syncope – due to hypovolaemia and cerebral hypoperfusion
Signs
- Tachycardia
- Hypotension
- Tender abdomen
- Malaena on rectal examinaton
Investigation results
- Sudden drop in haemoglobin
- Sudden rise in urea
- Endoscopy: bleeding ulcer/variceal rupture
Tips before you begin
- Treat all problems as you find them
- Re-assess regularly and after every intervention to see if your management is effective
- Make use of the team around you to delegate tasks where appropriate – is another clinical member of staff available to help you?
- All critically unwell patients should have continuous monitoring equipment attached for accurate observations, blood pressure and if necessary ECG readings – this will save you time!
- Communicate how often would you like these readings to be relayed to you
- If you need senior input for your patient, call for help early using an appropriate SBARR handover structure (check out the guide here)
- Review results (e.g. laboratory investigations) as they become available
- Make use of medical school/hospital guidelines and algorithms in managing specific situations such as haematemesis
- Medications or fluids will need to be prescribed
- Your assessment and management should be documented in the notes
Initial steps
You are likely to see this patient after a brief handover from another member of staff.
Introduction
Introduce yourself to whoever has requested a review of the patient.
Inspection
Perform a quick general inspection of the patient to get a sense of how unwell they are:
- Check consciousness level using AVPU
- How do they look? Are they pale?
- How is their breathing?
- Are there obvious signs of bleeding?
- What is around the bedside? (look for IV lines, bowls of vomit/blood, monitoring equipment etc).
Interaction
- Introduce yourself to the patient
- Ask the patient how they are doing- in what way are they feeling unwell?
- Are they in pain?
Preparation
- Make sure the patient notes, observation chart and prescription chart are on hand (this should not delay your immediate clinical assessment)
- 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
Assessment
Can the patient talk?
YES:
- Airway is patent; move on to Breathing assessment
NO:
- Look for signs of airway compromise (e.g. see-saw breathing, use of accessory muscles, diminished breath sounds, added sounds)
- Is the patient cyanosed?
- Open the mouth and inspect: is there anything obviously compromising the airway (e.g. vomit/blood)?
Intervention
In any case of airway obstruction, seek immediate expert help from an anaesthetist. You may need the crash team. In the meantime, you can perform some basic airway manoeuvres to help maintain the airway.
Maintain the airway whilst awaiting senior input
1. Perform head tilt, chin lift manoeuvre.
2. If noisy breathing persists try a jaw thrust.
3. If airway still appears compromised use an airway adjunct:
- Insert an oropharyngeal airway (Guedel) only if unconscious (as otherwise may gag/aspirate)
- Alternatively, use a nasopharyngeal airway (better tolerated if the patient is partially conscious)
Breathing
Assessment
Observations
Oxygen saturation – aim for 94-98%
Respiratory rate:
- Tachypnoea can be related to significant acute blood loss (>1500mls)
- A falling or normal respiratory rate in the context of hypoxia is a sign of impending respiratory failure and need for urgent critical care review
Examination
Auscultate lungs:
- Assess air entry and listen for added sounds – if the patient has been vomiting they may have aspirated (e.g. reduced air entry and coarse crackles at the right base)
Intervention
Oxygen
- Sit the patient upright
- Administer oxygen 15L via a non-rebreathe mask
Ensuring the patient is well oxygenated is important, but be ready to quickly remove the mask during episodes of haematemesis as this can result in aspiration.
Circulation
Assessment
Observations
Heart rate – tachycardia can be an early sign of volume depletion
Blood pressure – hypotension doesn’t typically occur until there has been significant blood loss (1500-2000mls), so if hypotension is present this is a concerning sign.
Classification of haemorrhagic shock 1
Examination
Inspect:
- Pallor suggests significant anaemia
- Jugular venous pressure: reduced in hypovolaemia, but often difficult to assess clinically
Feel:
- Assess peripheries – these will often be cool in patients with acute blood loss due to hypovolaemia
- Capillary refill time – prolongation (>2 seconds) suggests hypovolaemia
- Assess peripheral pulse for rate and rhythm (tachycardia and a thready pulse suggests volume depletion)
- Assess for peripheral oedema – may be present in cirrhotic patients with variceal bleeds
Investigations/Procedures
Intravenous access
Insert two large bore cannulae (14-16G)
This is essential in the context of upper gastrointestinal bleeding as patients can quickly become haemodynamically unstable and require large volumes of fluid and blood to be transfused.
Bloods
Take blood samples after inserting the cannula:
- Full blood count (FBC) – Hb may be decreased in the context of acute blood loss
- Coagulation studies – deranged in liver disease and may indicate the need to replace clotting factors
- Group and Crossmatch – requesting blood early is essential – in emergency use O negative blood
- U&Es – raised urea occurs in UGIB due to digestion and absorption of blood proteins
- LFTs – if liver disease is suspected then this can assist in confirming the diagnosis
Monitor fluid balance
It’s useful to monitor urine output in haemodynamically unstable patients because urine output provides a proxy measurement of end-organ perfusion. If the kidneys are not getting sufficient perfusion, urine output falls.
Commence a fluid balance chart if not already in place to allow accurate monitoring of fluid status.
Plan to catheterise if appropriate.
Aim for a urine output of >30mls/hr.
Intervention
Intravenous fluid resuscitation and blood transfusion
Intravenous fluid
- Patients’ with UGIB are often haemodynamically unstable
- Intravenous fluid is useful for replacing volume loss and improving end-organ perfusion
- No difference in outcome has been demonstrated between crystalloid and colloid fluid, however, colloid fluid does carry a small risk of anaphylaxis. As a result, you should usually use crystalloid fluids unless they are unavailable
- The rate of fluid replacement depends on the rate of loss (BP and urine output can help guide this)
- If the patient is losing significant volumes of blood, fluid replacement alone is inadequate and blood transfusion needs to be arranged
Blood transfusion
- Haemoglobin level can be misleading in acute bleeds as it may only decrease once haemodilution has occurred after intravenous fluid administration
- Base decisions on blood transfusion on the full clinical picture, recognising that over-transfusion may be as damaging as under-transfusion
- Give compatible blood when available
- The rate of transfusion should be guided by haemoglobin level and estimated blood loss
- If the patient is losing blood rapidly then don’t wait for crossmatching and give O-negative blood instead (this would be a senior led decision)
Platelets and clotting factors
Patients’ may have deranged platelets and clotting factors which are contributing to the bleed. This is often due to pre-existing liver disease and splenomegaly.
NICE guidance in regard to the use of platelets and clotting factors is shown below: ²
Platelets
- If a patient is not actively bleeding and is haemodynamically stable, platelets should not be administered
- Only offer platelets to patients actively bleeding with a platelet count <50 x109/L
Fresh frozen plasma (FFP)
Offer fresh frozen plasma to patients who have either:
- Fibrinogen <1g/litre
- Prothrombin > 1.5 times the normal level
This should be a consultant led decision with haematology input.
Prothrombin complex
Give prothrombin complex concentrate to those taking warfarin and actively bleeding.
This should be a consultant led decision with haematology input.
Recombinant factor VIIa
Only offer recombinant factor VIIa when all other methods have failed.
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.² It should be stopped once definitive haemostasis has been achieved.
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/day for seven days.
Endoscopy
Endoscopy should be performed on all unstable patients with severe UGIB immediately after resuscitation.² It should be performed within 24 hours of admission for all other patients with UGIB. This allows the diagnostic confirmation and the opportunity to treat any bleeding sites.
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 not offering acid-suppression drugs (proton pump inhibitors or H2-receptor antagonists) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding.
Disability
Assess the patient’s level of consciousness using AVPU – decreased consciousness may suggest cerebral hypoperfusion and/or hepatic encephalopathy
Check capillary blood glucose – often deranged in liver disease
Exposure
Adequate exposure is essential to ensure you don’t miss diagnostic clues:
- Rectal examination – melaena – UGI bleeding
- Stigmata of chronic liver disease – spider naevi, caput medusae, ascites
- Bruising – may indicate coagulopathy
- Evidence of trauma/blood loss from other sites
Reassess ABCDE
It is essential to continually reassess ABCDE and treat issues as you encounter them. This allows continual reassessment of the response to treatment and early recognition of deterioration.
If the patient does not respond to treatment or deteriorates, critical care input should be involved as soon as possible.
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 GI haemorrhage have a Blatchford score of zero. Such patients’ can largely be managed safely in the community, as the mortality in this group is nil.³
Blatchford Scoring System 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
Rockall Scoring System. NICE Guidelines ²
Next steps
Well done! You’ve stabilised the patient and they’re doing much better. Just a few more things to do…
Take a history
Take a more detailed history of what has happened and how the patient has been. Involve staff or family members as appropriate.
Check out our history taking guides here
Review
Review the patient’s notes, observations, fluid charts, and any investigation findings. Double check the medications you have just prescribed, and any routine medications the patient is taking.
Document
Document your ABCDE assessment clearly, including examination, observations, investigations, interventions, and patient response/changing condition. Write down any pertinent details from your history-taking.
Discuss
If a senior doctor hasn’t already been involved, it is important to contact them and make them aware of the unwell patient. As a junior doctor, it would be appropriate to give an SBARR handover outlining your assessment and actions, and to discuss the following:
- Are any further assessments or interventions required?
- Does the patient need a referral to HDU/ICU?
- Should they be referred for a review by a speciality doctor?
- Should any changes be implemented to the management of any underlying conditions?
Handover
The next team of doctors on shift should be made aware of any patient in their department who has become acutely unwell.
References
