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Upper GI Bleed

Checked: 23-12-2020 by Rob Adams Next Review: 23-12-2021

Overview

Upper gastrointestinal bleeding can manifest as:

haematemesis - the vomiting of frank blood
melaena* - the passing of altered blood per rectum. Typically maleana is the passage of black, tarry stools. The stools have a characteristic and offensive smell due to the presence of blood that has been digested by intestinal enzymes and bacteria (1).

See NICE guideline CG141: Acute Upper Gastrointestinal Bleeding in Over 16s: management (last update August 2016)

Acute upper gastrointestinal bleeding is a common medical emergency that has a 10% hospital mortality rate.

It is therefore important that all patients who present with acute bleeding should be initially assessed in hospital using the Glasgow Blatchford Bleeding score (GBS) (2) and the full Rockall score after endoscopy (if indicated).

Local gastroenterologists advise that some patients who are assessed in hospital and have a GBS of 0 or 1 may not need an endoscopy but may be discharged with a PPI and safety-netting advice. All patients with GBS of 2 or above will be admitted for inpatient OGD.

* Differential diagnosis of melaena includes dark stools due to ingestion of iron tablets, liquorice, charcoal or bismuth. Note that these substances tend to cause small well-formed non-tarry stools and there is no associated offensive smell.(1)

(1) Malaena - GP notebook

Referral

Acute bleeding

Patients who are haemodynamically unstable or have active bleeding should ring 999 for an emergency ambulance.

Patients who present in the community and who are stable and are not actively bleeding (but have had symptoms of upper GI bleed within the last 7 days) should be discussed with the Medical Assessment/Admission and Weekday IUC Professional Line (IUC Professional Line: 0117 244 9283). These patients are at risk of re-bleeding and referral for a community endoscopy is not appropriate (the community service cannot clip or inject actively bleeding peptic ulcers or band varices).

Non- acute bleeding

Patients who present more than 7 days following symptoms should be assessed in primary care. Risk factors should be addressed and urgent bloods should be undertaken (including FBC, UE, LFT, clotting) and one of the following referral routes considered:

Upper GI Urgent Suspected Cancer - USC (2WW) - if cancer is suspected and criteria are met.
Community endoscopy referral via eRS (Please mark urgent and referrals will be triaged and seen as appropriate).
Referral to Gastroenterology via eRS (upper GI)
Gastronenterology Advice and Guidance

Safety-netting in these patients is very important and if the patient has further symptoms of an acute bleed they should be advised to call 999.

Resources

(2) Glasgow-Blatchford Bleeding Score:

Glasgow-Blatchford Bleeding Score (GBS) - MDCalc

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