Clinical reasoning notes. Resuscitate first, diagnose second.
The reasoning chain: is the patient shocked → resuscitate (airway, IV access, fluids, blood) → stratify risk → find the cause (ulcer or varices?) → endoscopy within 24 hours → treat the cause and prevent rebleeding.
1. Recognise it
Haematemesis (vomiting blood, red or "coffee-ground") and melaena (black, tarry, foul-smelling stool). Rapid bleeding can give fresh red blood per rectum with shock. The bleed is upper if it arises above the ligament of Treitz (oesophagus, stomach, duodenum).
2. Assess severity and resuscitate (ABC first)
- Shock signs: pulse above 100, systolic BP below 100, cold peripheries, low urine output, confusion.
- Two large-bore IV cannulae, group and crossmatch, give crystalloid, and transfuse blood for shock or ongoing bleeding. A restrictive threshold (about 7 g/dL) is usually used, higher with heart disease.
- Correct clotting problems (stop warfarin and give vitamin K or specific reversal; consider platelets if very low).
- Catheterise to monitor urine output; give oxygen.
- Be alert for airway protection in a patient who is vomiting blood and drowsy.
Risk score (Glasgow-Blatchford): uses urea, haemoglobin, systolic BP, pulse, melaena, syncope, liver disease and heart failure to decide who needs admission and urgent endoscopy. A score of 0 means very low risk and outpatient care is possible.
3. Find the cause
| Cause | Clues |
|---|---|
| Peptic ulcer (duodenal or gastric) | Epigastric pain, NSAIDs, aspirin, H. pylori, previous ulcer |
| Oesophageal or gastric varices | Known or suspected cirrhosis, jaundice, ascites, spider naevi, splenomegaly, alcohol, hepatitis B, schistosomiasis with portal hypertension; massive bleeding |
| Gastritis or erosions | Alcohol, NSAIDs, stress in a sick patient |
| Mallory-Weiss tear | Retching, then fresh blood after repeated vomiting |
| Oesophagitis, cancer, angiodysplasia, Dieulafoy lesion | Less common |
Think local: in many African settings, bleeding varices from cirrhosis (hepatitis B or schistosomiasis) are a leading cause, and the management differs from that of an ulcer.
4. Investigate with purpose
| Test | The question it answers |
|---|---|
| Haemoglobin | How much has been lost? (It may be normal in the first hours.) |
| Urea and creatinine | A raised urea with a normal creatinine suggests an upper GI bleed (blood is digested as protein) |
| Group and crossmatch, clotting screen, platelets | Blood ready? Coagulopathy? |
| Liver tests, albumin, INR | Is there cirrhosis and how severe? |
| ECG and troponin | Anaemia can cause ischaemia in older patients |
| Upper GI endoscopy within 24 hours | The cause, the risk of rebleeding, and treatment in one test |
| H. pylori test | If an ulcer is found |
5. Management by cause
Peptic ulcer
- High-dose IV proton pump inhibitor (before endoscopy in many protocols).
- Endoscopic therapy (injection, clips, thermal) for high-risk ulcers.
- Test for and treat H. pylori, stop NSAIDs, continue PPI for ulcer healing.
- If endoscopy fails: interventional radiology embolisation or surgery.
Variceal bleeding (an emergency with high mortality)
- Resuscitate cautiously (do not over-transfuse: it raises portal pressure and rebleeding).
- Vasoactive drug (terlipressin or octreotide) started at once.
- Antibiotic prophylaxis (such as ceftriaxone): reduces infection and death.
- Endoscopic band ligation within 12 hours.
- If bleeding is uncontrolled: balloon tamponade (Sengstaken-Blakemore tube) or TIPS as a bridge.
- After the bleed: non-selective beta-blocker (propranolol or carvedilol) plus repeated band ligation to prevent rebleeding; treat the cirrhosis.
6. Where management can go wrong
- Over-transfusion in varices raises the portal pressure and bleeding.
- Giving a PPI does not replace endoscopy.
- Not taking an NSAID or aspirin history (including over-the-counter and herbal remedies).
- Missing hepatic encephalopathy: blood in the gut can trigger it, so treat with lactulose.
Examiner questions
- How do you resuscitate a patient with haematemesis and shock?
- Why can the urea be high with a normal creatinine in an upper GI bleed?
- How does the management of variceal bleeding differ from an ulcer bleed?
Practice questions
1. A 55-year-old with cirrhosis has a large haematemesis and BP 80/50. Which drug should be started at once? A. Oral omeprazole · B. Terlipressin or octreotide, with antibiotic prophylaxis · C. Ibuprofen · D. Warfarin · E. Propranolol only Answer: B.
2. The best timing of endoscopy in a stable upper GI bleed is: A. After a week · B. Only if bleeding recurs · C. Within 24 hours · D. Never · E. After a barium swallow Answer: C.
3. A raised urea with a normal creatinine in a patient with melaena suggests: A. Kidney failure · B. An upper gastrointestinal bleed · C. Dehydration only · D. Liver failure · E. A lower GI bleed Answer: B.
4. After a variceal bleed, the best long-term prevention of rebleeding is: A. Aspirin · B. NSAIDs · C. A non-selective beta-blocker plus endoscopic band ligation · D. Warfarin · E. Antacids Answer: C.