Red flags1 exam ›
- Haemodynamic instability: HR >100, SBP <100, postural drop, shock index >1
- Haematemesis (fresh red > coffee-ground)
- Haematochezia with haemodynamic instability = upper GI bleed until proven otherwise (~10-15% of apparent lower GI bleeds)
- Signs of chronic liver disease -> variceal bleeding
- Haematemesis + splenomegaly in a child = oesophageal varices from portal hypertension until proven otherwise
- Anticoagulant or antiplatelet therapy
- Ongoing bleeding despite resuscitation; rising lactate
- Aortic graft in situ -> aorto-enteric fistula (a small herald bleed precedes exsanguination)
- Age >60, significant comorbidity, inpatient onset - all raise mortality
Differential by mechanism1 exam ›
Upper GI (proximal to the ligament of Treitz)
- Peptic ulcer ~40-50% - H. pylori, NSAIDs, aspirin
- Oesophagogastric varices and portal hypertensive gastropathy
- Mallory-Weiss tear (retching then haematemesis)
- Oesophagitis, gastritis, duodenitis
- Malignancy
- Dieulafoy lesion; angiodysplasia; GAVE (watermelon stomach)
- Aorto-enteric fistula; haemobilia; haemosuccus pancreaticus
Lower GI
- Diverticular disease - the commonest cause of major lower GI bleeding (painless, brisk, usually self-limiting)
- Angiodysplasia - elderly, recurrent, right colon
- Haemorrhoids and anal fissure - the commonest cause overall
- Colitis - IBD, ischaemic, infective, radiation
- Neoplasia - cancer, post-polypectomy bleeding
- Meckel diverticulum; small bowel angiodysplasia, tumour, NSAID enteropathy
By age
- Infants - bacterial enteritis, cows' milk protein allergy, intussusception, swallowed maternal blood, anal fissure, lymphonodular hyperplasia
- Children - + colonic polyps, peptic ulcer/gastritis, swallowed epistaxis, Mallory-Weiss
- Adolescents - IBD, peptic ulcer/gastritis, Mallory-Weiss, colonic polyps, anal fissure
Focused history1 exam ›
Define the bleeding
- Haematemesis = vomited blood -> oesophagus, stomach or duodenum
- Melaena = black tarry offensive stool; needs ~50 mL and ~14 h transit. Usually upper, can be small bowel or right colon
- Haematochezia = red or maroon blood per rectum -> source distal to the distal ileum, OR a massive upper GI bleed
- Volume, frequency, duration; blood on the paper vs mixed through stool
- Vomiting/retching first, then haematemesis = Mallory-Weiss**
Drivers
- NSAIDs, aspirin, antiplatelets, anticoagulants, SSRIs, corticosteroids, bisphosphonates
- Alcohol; known liver disease or risk factors for it
- Previous ulcer, H. pylori, previous bleed, previous endoscopy
- Weight loss, dysphagia, change in bowel habit -> malignancy
- Previous aortic graft or AAA repair
- Recent polypectomy; recent radiotherapy
- Beetroot, iron, bismuth (black stool that is not melaena)
Comorbidity that changes management
- Ischaemic heart disease (transfusion threshold, antiplatelet decisions), CKD, cirrhosis
Focused examination
- Haemodynamics first - HR, BP, postural drop, capillary refill, conscious state, urine output
- Stigmata of chronic liver disease - jaundice, spider naevi, palmar erythema, ascites, splenomegaly, caput medusae, asterixis
- Abdomen - tenderness, mass, hepatosplenomegaly, scars, aortic graft scar
- PR examination - melaena vs fresh blood vs a rectal mass; anoscopy for haemorrhoids
- NG aspirate may confirm an upper source (a clear aspirate does not exclude a post-pyloric bleed)
- Telangiectasia on lips/tongue - hereditary haemorrhagic telangiectasia
- Pigmented macules - Peutz-Jeghers; pseudoxanthoma elasticum skin changes
Investigation strategy1 exam ›
Bloods
- FBE (Hb is falsely reassuring early - before haemodilution), UEC, LFT, coagulation profile, group and hold/crossmatch, lactate, VBG
- Urea:creatinine ratio raised in upper GI bleed (protein load + hypovolaemia)
Risk scores
- Glasgow-Blatchford score - pre-endoscopy; score 0-1 = safe for outpatient management
- Rockall - post-endoscopy mortality
- AIMS65 - mortality
- Oakland score for lower GI bleeding
Endoscopy
- Gastroscopy within 24 h of an upper GI bleed; within 12 h if variceal bleeding suspected or haemodynamically unstable
- Forrest classification - stratifies re-bleeding risk of a peptic ulcer without endoscopic treatment:
| Forrest | Appearance | Re-bleed risk |
|---|---|---|
| Ia/Ib | Active arterial (spurting) / oozing bleeding | Near 100% (Ia) |
| IIa | Non-bleeding visible vessel | Up to 50% |
| IIb | Adherent clot | 8-35% |
| IIc | Flat pigmented spot | ~10% |
| III | Clean base | <5% |
- Forrest Ia-IIb warrant endoscopic therapy; IIc and III do not
- Colonoscopy for lower GI bleeding after bowel preparation (usually within 24 h once stable)
When endoscopy is negative or bleeding is obscure
- CT angiography - needs bleeding at >=0.3-0.5 mL/min; localises before angiographic embolisation
- Capsule endoscopy for obscure small bowel bleeding (avoid if stricture suspected)
- Balloon-assisted (double-balloon) enteroscopy - diagnostic and therapeutic
- Technetium-labelled red cell scan - detects slower bleeding (0.1 mL/min) but localises poorly
- Meckel scan (technetium pertechnetate) in children/young adults
Management3 exam ›
1. Resuscitate first - always
- Two large-bore cannulae, crystalloid, crossmatch
- Restrictive transfusion: target Hb 70-80 g/L
- Higher threshold (80-100) only in active ischaemia. In variceal bleeding over-transfusion raises portal pressure and provokes rebleeding
- Correct coagulopathy: vitamin K + Prothrombinex-VF for warfarin; idarucizumab for dabigatran; andexanet alfa or PCC for factor Xa inhibitors; platelets if <50 x10^9/L and bleeding
- Airway protection if massive haematemesis or encephalopathy
- Withhold antihypertensives, diuretics, anticoagulants
2. Upper GI bleed - non-variceal
- High-dose IV PPI (80 mg bolus then 8 mg/h, or high-dose oral) - may downstage endoscopic findings but does not replace endoscopy
- Endoscopic haemostasis for Forrest Ia-IIb: two modalities - adrenaline injection plus a second (clip, thermal coagulation, haemostatic powder)
- After successful haemostasis: PPI infusion 72 h, then oral PPI
- **H. pylori testing in every ulcer bleed - and re-test for eradication after treatment* (false negatives are common during acute bleeding, so re-test if negative*)
- Rebleeding -> repeat endoscopy; then angiographic embolisation; surgery last
- Restart aspirin early if secondary prevention (the cardiovascular risk of stopping usually exceeds the rebleeding risk)
3. Variceal bleeding
- Terlipressin (or octreotide) + IV ceftriaxone prophylaxis - both independently reduce mortality
- Endoscopy within 12 h -> band ligation (oesophageal) or cyanoacrylate glue (gastric)
- Failure -> balloon tamponade (Sengstaken-Blakemore/Minnesota) or oesophageal stent as a bridge -> rescue TIPS
- Pre-emptive TIPS within 72 h in high-risk patients (Child C <14, or Child B with active bleeding at endoscopy)
- Bleeding risk: ~12% overall (5% small varices, 15% large); recurrent bleeding 15-20% within a year of a first bleed
- High risk: large varices, red wale marks, Child-Pugh B/C, HVPG >12 mmHg, variceal pressure >15 mmHg, hepatofugal portal flow
- Primary prophylaxis: carvedilol preferred over propranolol (also reduces decompensation, not just bleeding), or band ligation if beta-blocker not tolerated
- No mortality difference between beta-blockade and banding
- Secondary prophylaxis: NSBB + band ligation programme; TIPS for recurrent bleeding; transplantation is definitive
4. Lower GI bleed
- Most stop spontaneously - resuscitate and observe
- Colonoscopy after preparation -> clip, adrenaline, thermal therapy, band ligation
- Ongoing bleeding -> CT angiography then transcatheter embolisation
- Surgery only if uncontrolled and localised
- Haemorrhoids -> banding, sclerotherapy
Traps
- Melaena with shock and a normal-looking gastroscopy: look again, and look distally - post-bulbar duodenal ulcers and Dieulafoy lesions are easily missed
- *A normal haemoglobin early in an acute bleed means nothing* - haemodilution takes hours
- Haematochezia in an unstable patient is an upper GI bleed until an NG aspirate or gastroscopy says otherwise
- Beetroot, iron and bismuth mimic melaena; a clear NG aspirate does not exclude a duodenal source
- H. pylori testing is falsely negative during acute bleeding and on PPI - re-test after
- An aortic graft plus a herald GI bleed = aorto-enteric fistula. CT before endoscopy
- Do not over-transfuse a variceal bleed - it raises portal pressure and provokes rebleeding
- Stopping aspirin indefinitely after an ulcer bleed causes more deaths from cardiovascular events than it prevents from rebleeding
- A cirrhotic with any GI bleed needs antibiotic prophylaxis, whatever the source
- Angiodysplasia is often multiple and recurrent - a single treated lesion does not end the problem
- NSAIDs (including topical and over-the-counter) are routinely denied on direct questioning - ask about specific brands
Talk track
1. Resuscitation before diagnosis
- "My first priority is haemodynamic assessment and resuscitation - two large-bore cannulae, crossmatch, and a restrictive transfusion target of 70 to 80."
2. Upper or lower, and variceal or not
- "The stigmata of chronic liver disease change everything - if I suspect varices I give terlipressin and ceftriaxone before the endoscope."
3. Risk-stratify
- "A Glasgow-Blatchford of 0 to 1 can go home; anything higher is admitted for endoscopy within 24 hours, or 12 if unstable or variceal."
4. Endoscopy with a plan
- "Forrest Ia to IIb get dual-modality endoscopic haemostasis and a 72-hour PPI infusion."
5. Prevent the next one
- "Then H. pylori eradication and confirmation of cure, a rethink of the NSAID and antiplatelet regimen, and for varices, carvedilol plus a banding programme.
Study aid only. These notes are written with the help of AI. Not for guiding clinical decisions.