One-page cheat sheet
Upper GI bleeding
Resuscitate, risk-score, scope
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Causes
- Peptic ulcer (most common): NSAIDs, H. pylori
- Varices (liver disease), oesophagitis, gastritis
- Mallory-Weiss tear, malignancy, Dieulafoy lesion
Assessment
- ABC; two large-bore cannulae; FBC, U&E (urea rises), LFTs, clotting, group and crossmatch
- Glasgow-Blatchford before endoscopy: 0–1 can be managed as an outpatient
- Rockall after endoscopy: rebleeding and death
- Ask about NSAIDs, anticoagulants, alcohol, liver disease
Resuscitation
- Restrictive transfusion: Hb threshold 70 g/L (80 with heart disease)
- Platelets if under 50 and bleeding; FFP if PT/INR over 1.5 times normal
- Warfarin with active bleeding: prothrombin complex concentrate
- Major haemorrhage protocol when needed
Endoscopy
- Within 24 hours; immediately after resuscitation if unstable
- Ulcer with active bleeding or visible vessel: adrenaline plus clips or thermal therapy (never adrenaline alone)
- High-dose PPI after endoscopic haemostasis
- Rebleed: repeat endoscopy, then radiological embolisation, then surgery
Varices
- Terlipressin and antibiotics before endoscopy
- Band ligation for oesophageal varices; tissue glue for gastric varices
- Uncontrolled: balloon tamponade as a bridge, then TIPS
Don’t miss
- Aorto-enteric fistula after aortic graft surgery
- Haemodynamic instability in young patients is a late sign
- Test for H. pylori and stop NSAIDs
Exam pearls
- Forrest Ia spurting, Ib oozing, IIa visible vessel, IIb clot, IIc spot, III clean
- Melaena usually means bleeding above the ligament of Treitz
- NICE: no PPI before endoscopy for non-variceal bleeding