Key Facts

Upper GI bleeding (UGIB) accounts for ~80% of acute GI bleeding and is a common medical emergency. Advances in endoscopic therapy and PPI use have improved outcomes, but mortality remains ~10% due to an aging comorbid population.

Epidemiology

Incidence ~100-150 per 100,000 per year in UK. ~70,000 hospital admissions/year. Mortality ~10% (higher in inpatient bleeding ~30%). Peptic ulcer disease is the commonest cause overall.

Aetiology

• Peptic ulcer disease: 35-50% (DU > GU)
• Oesophageal/gastric varices: 10-20%
• Erosive oesophagitis/gastritis: 10-15%
• Mallory-Weiss tear: 5-10% (post-vomiting/retching mucosal tear at GOJ)
• Upper GI malignancy: 2-5%
• Dieulafoy lesion: 1-2% (aberrant submucosal artery with small overlying mucosal defect)
• Angiodysplasia: 1-2%
• Aorto-enteric fistula: rare but catastrophic (history of aortic graft)

Pathophysiology

Peptic ulcer bleeding: ulcer erodes into a blood vessel (usually posterior duodenal ulcer eroding into gastroduodenal artery). Variceal bleeding: see oesophageal varices entry. Mallory-Weiss: longitudinal mucosal tear at GOJ from forceful vomiting/retching; usually self-limiting.

Presentation

• Haematemesis: fresh red blood (active/severe) or coffee-ground (slower/altered)
• Melaena: black, tarry, offensive stools
• Haematochezia: fresh PR blood (if massive UGIB — brisk transit)
• Syncope/pre-syncope (from blood loss)
• Signs of shock: tachycardia, hypotension, pallor, cold peripheries

Red Flags

• Haemodynamic instability (HR >100, SBP <100)
• Fresh ongoing haematemesis
• Known/suspected varices (liver disease stigmata)
• Anticoagulated patient
• Aortic graft history (aorto-enteric fistula — often herald bleed then massive)
• Witnessed collapse with haematemesis

Bedside

• A-E assessment: pulse, BP, SpO₂, RR, GCS
• DRE: melaena confirmation
• Glasgow-Blatchford Score: at presentation — determines urgency and disposition

Bloods

• FBC: Hb (may lag behind blood loss initially)
• U&Es: urea raised disproportionately in UGIB
• LFTs: liver disease assessment
• INR/coagulation: anticoagulant therapy, liver disease
• Group and crossmatch: 2-6 units
• Lactate: tissue perfusion

Endoscopy

• OGD: within 24 hours (within 12 hours if variceal suspected, haemodynamically unstable after resuscitation, or high-risk features)
• Forrest classification of ulcer bleeding guides management
• Endoscopic therapy: adrenaline injection (1:10,000 — for initial haemostasis) PLUS thermal or mechanical (clips) for definitive haemostasis; band ligation for varices

Imaging

• CT angiography: if massive bleeding and endoscopy unable to localise/control
• Mesenteric angiography: diagnostic and therapeutic (embolisation)
• CT thorax/abdomen: if aorto-enteric fistula suspected

Non-pharmacological

• Resuscitation: 2 large-bore cannulae, IV crystalloid, crossmatch
• Restrictive transfusion: target Hb 70-80 g/L (Villanueva et al. NEJM 2013 — improves survival vs liberal transfusion, especially in variceal bleeding)
• Correct coagulopathy: vitamin K 5-10 mg IV for warfarin; idarucizumab for dabigatran; prothrombin complex concentrate for life-threatening bleeding on VKAs
• Keep NBM until endoscopy

Pharmacological

• Non-variceal UGIB:
  • Pre-endoscopy PPI: IV omeprazole 80 mg bolus (does not reduce mortality but may reduce high-risk endoscopic stigmata)
  • Post-endoscopy (high-risk — Forrest Ia-IIb): IV omeprazole 80 mg bolus then 8 mg/hr × 72 hours, then switch to oral PPI
  • H. pylori test and treat: all peptic ulcer patients
  • Review/stop NSAIDs: if NSAID-related; co-prescribe PPI if NSAID essential
• Variceal UGIB:
  • Terlipressin 2 mg IV stat then 1-2 mg QDS × up to 5 days
  • Prophylactic antibiotics: ceftriaxone 1 g IV OD × 5-7 days
  • OGD band ligation: within 12 hours
  • Early TIPSS: within 72 hours for high-risk (Child C 10-13 or Child B with active bleeding at OGD)
  • Balloon tamponade (Sengstaken-Blakemore): temporary bridge if endoscopy unavailable or failed (max 24 hours)

Surgical/Interventional

• Rebleeding after endoscopic therapy: repeat OGD first; if fails → interventional radiology (embolisation) or surgery
• Surgery: under-running of bleeding vessel (duodenal ulcer → gastroduodenal artery), partial gastrectomy (rarely needed now)
• TIPSS: for variceal bleeding (see above)

Referral Criteria

• GBS 0: consider outpatient OGD (safe early discharge)
• GBS ≥1: inpatient management
• Variceal bleeding: urgent GI/hepatology
• Failed endoscopic haemostasis: IR + surgical standby

Overall UGIB mortality ~10%. Peptic ulcer bleeding rebleeding rate after endoscopic therapy ~5-10%. Variceal bleeding mortality 15-20% per episode. Mallory-Weiss tears: self-limiting in >90%. GBS 0 patients have <1% risk of requiring intervention. Inpatient UGIB has worse prognosis (~30% mortality) due to comorbidities. Restrictive transfusion strategy reduces mortality compared to liberal strategy.

Forrest Classification of Peptic Ulcer Bleeding

Key Guidelines and Trials