Upper GI bleed management

Include in assessment

  • Examination: ensure you look for signs of common causes (e.g. chronic/decompensated liver disease) and do PR exam (for melaena)
  • Bloods: G&S/crossmatch, FBC (blood loss), U&Es (↑urea in GI bleeds), LFTs (varices risk), clotting (coagulopathy common in liver disease), glucose
  • Catheterise (monitor UO)
  • CXR and AXR once stable (e.g. for aspiration, obstruction) 
  • OGD
  • Observations: check regularly

ABCDE Management

  • Follow usual ABCDE approach
    • IV fluid resuscitation (aim for systolic blood pressure ~100)
    • In massive blood loss, transfuse blood, FFP and platelets as per local massive haemorrhage protocol 
    • Blood transfusion if Hb <7g/L in variceal bleed, <8g/L in non-variceal bleed, or shock
    • The patient must be haemodynamically stable before endoscopy

Specific treatment

  • Acute variceal bleed (suggested by history/signs/results consistent with chronic liver disease or portal hypertension):
    • Terlipressin
    • Prophylactic IV antibiotics
    • Endoscopic intervention (variceal band ligation)
  • Non-variceal bleed (e.g. peptic ulcer, Mallory-Weiss tear, oesophagitis):
    • IV proton pump inhibitor
    • Endoscopic intervention (adrenaline injection, clips, or thermocoagulation)
  • In all patients:
    • Keep NBM
    • Transfuse as above
    • Correct any clotting abnormalities
      • On warfarin: prothrombin complex concentrate + vitamin K
      • On direct oral anticoagulant: Idarucizumab for dabigatran; Andexanet alfa for apixaban/rivaroxaban; consider prothrombin complex concentrate for others/if not available
      • ↓Platelets <50×109/L: platelet transfusion
      • ↑INR (not due to warfarin): vitamin K (if INR ≥1.5) ± FFP (if INR ≥2)
      • ↓Fibrinogen <1g/L: cryoprecipitate
    • Stop any antiplatelets or anticoagulants
    • Treat any concurrent issues, e.g. encephalopathy, alcohol withdrawal
  • Other interventions that are less commonly used
    • Balloon tamponade with Sengstaken-Blakemore tube
    • Interventional radiology (embolisation)
    • Surgical intervention
    • Transjugular Intrahepatic Portosystemic Shunt (for resistant varices)

Scoring systems

Glasgow-Blatchford score (pre-endoscopy)

  • Assesses likelihood patient will need intervention
  • Score 0 = can manage as outpatient; score ≥1 = manage as inpatient)
  • Takes into account haemoglobin, urea, SBP, sex, HR, presence of melaena, recent syncope, history of liver disease or heart failure (Blatchford et al. 2000)

Rockall score (post-endoscopy)

  • Mortality risk assessment
  • Score ≤2 = good prognosis; score >8 = high mortality risk
  • Takes into account age, shock, comorbidities, diagnosis and evidence of bleeding (Rockall et al. 1996)

Preventing further bleeding

Treat the cause/reduce the risk of re-bleeding:

  • Oesophageal varices
    • Carvedilol (β-blocker that reduces portal venous pressure)
    • Variceal banding
    • Transjugular Intrahepatic PortoSystemic Shunt
    • Liver transplant
  • Peptic ulcer
    • Proton pump inhibitor
    • H. pylori eradication if +ve
    • Avoid precipitants, e.g. NSAIDs

Test your knowledge with some questions

How does terlipressin work in a variceal bleed?

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What is a TIPS? How is it undertaken and how does it work?

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A patient has a TIPS and then becomes confused. What has happened? What is your initial management?

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Hepatic encephalopathy is a common complication of a TIPS procedure. Management is supportive with lactulose and rifaximin. Learn more about complications of cirrhosis here.

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