• Upper gastrointestinal haemorrhage (UGIH) is blood loss from the oesophagus, stomach or duodenum

Symptoms and signs

• Coffee-ground vomit (dark brown, denatured blood in vomit)
• Haematemesis (bright red or clotted blood in vomit)
• Melaena (black, tarry, smelly stool containing digested blood) 
• Postural dizziness or fainting
• Evidence of severe bleeding - defined as presence of shock with tachycardia (heart rate >100 beats/min), hypotension (systolic BP <100 mmHg) and clammy skin, or of postural hypotension in patient who is not clinically shocked
• Evidence of anaemia
• Features of precipitating disease, jaundice, stigmata of liver disease
• Features of bleeding disorder (petechiae)
• Buccal or facial telangiectasia
• Bright red rectal bleeding (haematochezia) can occur in major UGIH and is associated with severe haemodynamic instability, but in the absence of hypotension is likely from lower gastrointestinal tract 

Previous history

• Enquire about:
• peptic ulceration
• previous bleeds
• liver disease
• family history of bleeding
• ulcerogenic medication/anticoagulants
• alcohol
• weight loss

• FBC
• U&E
• LFT
• INR
• ECG
• Non-severe bleeding
  
  • group and save (non-urgent)
• Severe bleeding
  
  • crossmatch (4 units) - notify blood transfusion laboratory of clinical problem and degree of urgency
• If admission required, repeat FBC and U&E after 4 hr

Assess for chronic liver disease and suspected varices

• If there is no past history, clinical or laboratory evidence of chronic liver disease and oesophageal varices not suspected
  
  • calculate Glasgow Blatchford score (GBS)
• If there is evidence of chronic liver disease or varices are suspected (e.g. previous hospital notes, jaundice, ascites, spider naevi):
  
  • manage in hospital as variceal bleed and severe UGIH
  • admit to gastroenterology ward
  • see Oesophageal variceal bleeding section

Glasgow Blatchford Score to assess risk of death/rebleeding

• Score point for each of the following that are present. The greater the GBS score, the greater the risk of bleeding. Value >6 equates a 50% risk of rebleed and death
  
  • heart rate >100 beats/min
  • systolic BP <100 mmHg
  • postural hypotension (fall ≥20 mmHg 3 min after standing)
  • recent syncope 
  • melaena 
  • heart failure or liver disease
  • haemoglobin (Hb) <130 g/L (male), or <120 g/L (female)
  • urea >6.5 mmol/L
• If GBS >1 
  
  • manage in hospital as severe non-variceal bleed
  • admit to gastroenterology ward
• If GBS 1
  
  • manage in hospital as non-severe non-variceal bleed, but can be considered for early discharge
• If GBS 0
  
  • can be managed as outpatient - see Patients for possible discharge section below

• Send to observation unit 

Observations

2-hrly

• Heart rate
• BP: lying and standing at 3 min

Investigations

• Repeat FBC and U&E 4 hr after admission to CDU

Treatment

• None, unless specific cause or increase in severity identified

Admission criteria

• Glasgow Blatchford score ≥1
• Further episode of GI bleed
• Haemodynamic instability
• Abnormal blood results 

Criteria for discharge and outpatient OGD

• Glasgow Blatchford score 0
• No co-morbidities requiring acute admission
• Haemodynamically stable after 6 hr review
• Baseline bloods acceptable and no significant change in 4 hr Hb and U&E 
• No further episode of GI bleed
• Patient information pack provided to patient
• Request outpatient OGD 
• Give patient copy of discharge letter
• If inconclusive, repeat assessment 

Severe non-variceal UGIH

Immediate fluid resuscitation

• Insert 2 large bore (14-16 G) venous cannulae
• Infuse compound sodium lactate (Hartmann’s) solution (or, alternatively, sodium chloride 0.9%) 1-2 L over 30-120 min to achieve systolic BP >100 mmHg - see Fluid resuscitation and Maintenance fluid therapy guidelines
• In patients with significant cardiac disease, consider inserting central venous pressure (CVP) line to guide IV fluid replacement
• Measure urine output. Adequately resuscitated patients have urine output of 0.5 mL/kg/hr

Further management

Admission

• Admit to gastroenterology ward, 
• Keep patient nil-by-mouth

Review medication

• Stop antihypertensives, diuretics, NSAIDs, anticoagulants
  
  • if on warfarin, consider reversal with prothrombin concentrate complex (PCC), aim INR 2.5, see Management of bleeding and over-anticoagulation guideline
  • if on DOAC, consider reversal. See Bleeding in patient receiving DOAC guideline
  • patient with coronary stent inserted in last 12 months, liaise with cardiology

Transfuse

• If haemodynamically stable, only transfuse if Hb falls to 70-80 g/L
  
  • if increasing ischaemic heart disease symptoms, target Hb of 100 g/L 
• If haemodynamic compromise or continuous bleeding that will mask Hb changes, transfuse as soon as blood available - see Blood and blood products guidelines
  
  • prefer packed cells 
  • if 50% of total blood volume loss in 3 hr, follow Massive haemorrhage protocol with blood bank to obtain blood products rapidly 
• Transfuse 1 unit of platelets if platelet count <50 and 1 unit of cryoprecipitate if fibrinogen <1.0

Upper GI endoscopy

• Arrange upper GI endoscopy within 24 hr of presentation. Patients with ongoing haemodynamic instability will require endoscopy after resuscitation
  
  • contact gastroenterology unit

Consideration for surgery

• After preliminary resuscitation, discuss all patients with severe non-variceal bleeding with on-call surgical team. If appropriate, transfer patient to general surgical care for further management:
  
  • if doubt about realistic possibility of surgery, duty surgeon and duty physician to review patient in consultation
  • if any difficulties are encountered with this policy, inform on-call consultant physician. Contact a senior gastroenterologist via call centre only if on-call team unable to resolve the clinical management problem satisfactorily with duty surgical team
• Indications for surgical intervention (or interventional radiology under surgical care) are:
  
  • exsanguinating haemorrhage (too fast to replace or requiring >4 units of blood to restore blood pressure)
  • failed medical and/or endoscopic therapy
  • major rebleed after successful endoscopic therapy
  • special situation (e.g. patients with rare blood group or refusing blood transfusions)
• Once agreed with surgical team, transfer high-risk patients to Surgical Assessment Unit

Non-severe non-variceal UGIH

• Baseline observations 
• Order upper GI endoscopy within 24 hr/next available endoscopy list
• Wide bore IV access
• Allow food and drink until 4 hr before endoscopy
• No treatment necessary before endoscopy
• Send patient to acute GI unit or appropriately designated ward 

• Continue observations until know outcome of upper GI endoscopy
• Follow advice on the endoscopy report
• Calculate risk of rebleeding using Rockall score - see Table 1
  
  • if score of 2/11, can be discharged early

Table 1: Rockall score

Proton pump inhibitor

• If high risk stigmata identified on endoscopy, give omeprazole 80 mg by IV infusion over 40-60 min, then by continuous IV infusion of 40 mg in 100 mL sodium chloride 0.9% at 20 mL/hr (8 mg/hr) for 72 hr 

Eradication of H.pylori

If H. pylori identified and endoscopy report advises eradication, preferred regimen is:

• Give for 7 days 
  
  • absolute compliance with regimen essential for an eradication rate of 90%
  • if ulcer large, or complicated by haemorrhage or perforation, continue omeprazole for a further 21 days

Not allergic to penicillin

• Omeprazole 20 mg oral 12-hrly
• Amoxicillin 1 g oral 12-hrly
• Metronidazole 400 mg oral 12-hrly

Patients allergic to penicillin

• Omeprazole 20 mg oral 12-hrly
• Clarithromycin 500 mg oral 12-hrly
• Metronidazole 400 mg oral 12-hrly 
• Simvastatin contraindicated with clarithromycin 

After eradication of H.pylori

• If NSAID therapy reintroduced, continue omeprazole 20 mg oral daily for as long as NSAID required
• If neoplasm identified, refer to upper GI cancer team 

Patients who rebleed

• If an otherwise stable patient who is potentially referable for surgery rebleeds, request urgent endoscopy
  
  • discuss with on-call surgical team

Monitor

• 4-hrly heart rate and BP
• Observe vomit for blood content and stool chart for melaena
• Daily Hb until it is stable (not falling)
• In patients with severe bleeding, urine output
  
  • aim for >30 mL/hr 

• Discharge when stable

H.pylori positive duodenal ulcer

• Ask GP to arrange faecal antigen testing for H. pylori >4 weeks after completing eradication therapy

If H.pylori positive gastric ulcer

• Ask GP to arrange:
  
  • faecal antigen testing for H. pylori >4 weeks after completion of eradication therapy
  • repeat upper GI endoscopy to check healing 6-8 weeks following discharge
• If Hb still <100 g/L, start ferrous sulphate 200 mg oral 8-hrly

Non-severe bleeding with transient pathology (e.g. Mallory–Weiss tear, acute erosion)

• Discharge promptly after endoscopy with no follow-up

Non-severe bleeding and ulcer-related disease

• Discharge young stable patients (aged <45 yr) promptly after endoscopy
• Discharge older patients (aged >45 yr) when their condition is stable

Severe bleeding and ulcer-related disease

• Discharge when condition and Hb stable

Neoplasia

• Discuss further investigation and treatment with upper GI cancer team

Immediate fluid resuscitation

• Insert 2 large bore (14-16 G) venous cannulae
• Infuse compound sodium lactate (Hartmann’s) solution (or, alternatively, sodium chloride 0.9%) 1-2 L over 30-120 min to achieve systolic BP >100 mmHg - see IV fluid resuscitation and Maintenance fluid therapy guidelines, but avoid rapid fluid replacement as it increases risk of bleeding
• In patients with significant cardiac disease, consider inserting central venous pressure (CVP) line to guide IV fluid replacement
• Measure urine output. Adequately resuscitated patients have urine output of 0.5 mL/kg/hr

Review medication

• Stop antihypertensives, diuretics, NSAIDs, anticoagulants
  
  • if on warfarin, consider reversal with prothrombin concentrate complex (PCC) see Management of bleeding and over-anticoagulation with warfarin guideline 
  • if on DOAC, consider reversal. See Bleeding in patient receiving DOAC guideline 
  • patient with coronary stent inserted in last 12 months, liaise with cardiology

Transfuse

• If haemodynamically stable, only transfuse if Hb falls to 70-80 g/L
  
  • if ischaemic heart disease, target Hb of 100 g/L 
• If haemodynamic compromise or continuous bleeding that will mask Hb changes, transfuse as soon as blood available. See Blood and blood products guidelines
  
  • prefer packed cells 
  • if 50% of total blood volume loss in 3 hr, 
  • follow Massive haemorrhage protocol with blood bank to obtain blood products rapidly 
• Transfuse 1 unit of platelets if platelet count <50 and 1 unit of cryoprecipitate if fibrinogen <1.0

Treatment

• If INR raised discuss with haematology and gastroenterology on-call
• Continue fluid replacement but avoid rapid fluid replacement as it increases risk of rebleeding
• Aim to restore heart rate <100 beats/min, systolic BP >80 mmHg and Hb 70–80 g/L
  
  • if ischaemic heart disease, target Hb of 100 g/L 
• Give stat IV Vitamin K 10 mg (promotes coagulation) and metoclopramide 10 mg IV (promotes gastric emptying and improve endoscopic views)

Other initial management

Upper GI endoscopy

• Contact gastroenterology to discuss all suspected oesophageal variceal UGIH to arrange upper GI endoscopy as soon as possible.
  
  • contact gastroenterology unit

Terlipressin

• Whilst awaiting endoscopy, give terlipressin 2 mg IV bolus 
  
  • then 2 mg 6-hrly, duration directed by endoscopist
• Gastroenterology to review within 24 hr to advise on weaning off within 72 hr if no further bleeding
• If patient has risk factors for end-organ ischaemia due to peripheral vascular disease or ischaemic heart disease, repeat ECG and compare with admission trace
• Discuss maintenance terlipressin dose with on-call gastroenterologist

Octreotide

• If terlipressin not suitable, administer octreotide bolus 50 microgram IV, followed by continuous IV infusion of 50 microgram/hr

Antimicrobials

• Always obtain blood culture before giving an antimicrobial
  
  • see Collection of blood culture specimens guideline
• If septic, see Sepsis guideline

Penicillin allergy

• True penicillin allergy is rare 
• Ask the patient and record what happened when they were given penicillin 
• If any doubt about whether patient is truly allergic to penicillin, seek advice from a microbiologist or consultant in infectious diseases

Infection control alerts

• Check for IC alert
  
  • if IC alert not available, check previous 12 months of microbiology reports 
• If MRSA present, treat as tagged for MRSA. See MRSA management guideline
• If ESBL, MGNB, CARB present, treat as tagged for ESBL. See ESBL/MGNB/CARB management guideline

Not penicillin allergic

• Give tazocin 4.5 g IV 8-hrly for 3 days (adjust dose in renal failure)

Penicillin allergic patients

• Give aztreonam 1 g IV 8-hrly for 3 days
• Metronidazole 400 mg oral 12-hrly for 3 days
  
  • if nil-by-mouth, metronidazole 500 mg IV by infusion 8-hrly for 3 days

Previously MRSA colonised

• Add vancomycin IV by infusion. See Vancomycin guideline

Encephalopathy

• In patients with grade 4 encephalopathy, see Acute liver failure guideline
• Discuss endotracheal intubation with gastroenterology
  
  • if decided to intubate, contact critical care team
• If not already inpatient, admit 
• Contact gastroenterology team for advice on further management

Monitor

• 4-hrly heart rate and BP
• Observe vomit for blood content and stool chart for melaena
• Daily Hb until it is stable (not falling)
• In patients with severe bleeding, urine output
  
  • aim for >30 mL/hr 

• Discharge when stable
• Start carvedilol 6.25 mg oral once daily up titrating to maximum dose of 12.5 mg once daily aiming for heart rate of 50-55 beats/min and systolic blood pressure of 90 mmHg
  
  • if carvedilol not tolerated, start propranolol 40 mg oral 12-hrly, unless contraindicated, up titrating to maximum dose of 80 mg 12-hrly aiming for heart rate of 50-55 beats/min and systolic blood pressure of 90 mmHg as prophylaxis for further variceal bleeding
• If variceal banding performed to treat bleeding/high risk varices, ensure further variceal surveillance endoscopy has been booked for patient in 3-4 weeks from index procedure
• Refer to liver specialist for follow-up