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Management of Upper Gastrointestinal Bleeding (UGIB)

Introduction

Cardinal features are haematemesis (fresh red, or altered 'coffee ground' blood) and melaena. There may be associated collapse, haemodynamic instability, anaemia and an isolated rise in urea.

Liver disease and variceal bleeding have much higher mortality rates (refer to separate guidelines for management of Acute Liver Failure, Decompensated Liver Disease or Suspected Variceal Bleeding).

Assessment

See the British Society of Gastroenterology website for the Upper GI bleed (UGIB) care bundle.

  • ABCDE structured assessment with a focus on haemodynamic status (pulse and blood pressure), PR exam for melaena* and presence of signs suggestive of chronic liver disease (jaundice, ascites and encephalopathy).
  • Check FBC, U&Es, LFTs, coagulation screen / INR, and Group and Save or Crossmatch, as appropriate.
  • Calculate Glasgow Blatchford score (GBS) and stratify risk (≤1 = low risk and ≥2 = high risk).
  • Stratify UGIB by haemodynamic stability (stable vs unstable) and likely underlying aetiology (non-variceal vs variceal). If there is concern about variceal bleeding then refer to Suspected Variceal Bleeding.

*Presence of melaena implies that there has been significant blood loss.

General management

Pre-Endoscopy

All patients:

  • Suspend clopidogrel, other antiplatelets and anticoagulants
  • Continue aspirin but stop NSAIDs.
  • Consider reversing anticoagulation (depends on severity of bleeding and indication for anticoagulation, see guideline on Reversal of Antithrombotic Therapies).

N.B. Do not use tranexamic acid unless specifically advised by Gastroenterology (randomised trials have not shown efficacy in UGIB).

Haemodynamically unstable patients:

  • Nil by mouth
  • Crossmatch 4 units
  • IV access x 2 – use green (18G) needle or larger
  • Consider HDU
  • Resuscitate: Use sodium chloride 0.9% to keep pulse <100bpm, systolic BP >100mmHg, urine output >30ml/hour. Transfusion at threshold of 70-80g/L haemoglobin is recommended in most patients but should be considered at higher thresholds if significant ischaemic heart disease or major bleeding.
  • Discuss with on call Gastroenterologist regarding urgent endoscopy after resuscitation (should be done within 24 hours).
  • In patients not suspected to have a variceal UGIB and who are successfully resusciated, endoscopy may often be deferred to the next bleeding list in hospitals with daily bleeding lists (if any doubt over need for out of hours endoscopy then discuss with on call Gastroenterologist).

Haemodynamically stable patients:

  • Calculate Glasgow Blatchford score (GBS) to determine need for inpatient endoscopy.
  • If GBS score:
    • ≤1 (low risk) at presentation then patient can be discharged with early outpatient endoscopy arranged, unless admission required for other reasons.
    • ≥2 (high risk) at presentation then patient should have an endoscopy on the next available list, ideally within 24 hours.

Endoscopy

Methods for referring for endoscopy will vary according to hospital. If uncertain, ask for advice from a senior.

Before sending patient for inpatient endoscopy, ensure the following is arranged:

  • Fasted (minimum 3 hours)
  • Consent form signed or AWI (if patient has AWI in place for delirium, they will need a second separate form to cover the endoscopy)
  • Appropriate IV access in place
  • Group and Save or Crossmatch as appropriate
  • Ensure case notes and observation charts go with patient.

Post-endoscopy

  • Ensure endoscopy report is reviewed on return to ward in case action is required.
  • Assuming successful haemostasis, aspirin should be continued for secondary prevention of cardiovascular disease, with other antiplatelets and anticoagulation reintroduced on a case-by-case basis.
  • If no major stigmata of bleeding and no sinister pathology identified, consider patient for early discharge, unless advised otherwise in the report.

Peptic ulcer disease

If high risk stigmata requiring endoscopic therapy, treat as per Hong Kong protocol. This is an unlicensed indication and should only be prescribed at the request of the consultant. After infusion, initiate proton pump inhibitor (PPI) oral therapy. The duration of maintenance therapy is variable, as it is dependent on a number of factors. See the GGC guideline Proton Pump Inhibitors Prescribing on Discharge from Hospital for guidance. If no endoscopic therapy, prescribe either lansoprazole oral 30mg or omeprazole oral 20mg once daily.

Continue aspirin in patients with peptic ulcer disease (providing indication is still valid) but permanently stop NSAIDs. Suspend clopidogrel, other antiplatelets and anticoagulants in the acute bleeding situation but aim to restart once haemostasis is achieved. If patient is on dual antiplatelet therapy for coronary stents, discuss the risks versus benefits with the interventional cardiologist but clopidogrel should be withheld for a maximum of 5 days. 

Arrange a Helicobacter stool antigen test for patients with peptic ulcer disease:

  • If positive for H. pylori – see eradication regimen.
  • If negative for H. pylori and not on NSAIDs – maintain on lifelong PPI (see above for choice and dose).
  • If re-bleeding occurs (fresh melaena or haematemesis associated with a drop in Hb of 20g/L) – seek senior help, including surgical review.

If varices present, see separate guideline for management. 

On discharge

  • Continue PPI for at least 6 weeks.
  • Repeat endoscopy in 8 weeks if gastric ulcer found.
  • Ensure successful eradication of H.pylori (see Management of Helicobacter Pylori guideline).

 

Guideline reviewed: May 2023

Page last updated: December 2023