Background Information
Definition
Upper vs lower GI bleed is an anatomical definition:
- Upper GI bleed: bleeding that originates from a source proximal to the ligament of Treitz (duodenal-jejunal ligament)
- Lower GI bleed: source distal to the ligament of Treitz
Aetiology
Upper and lower GI bleeding causes (adults mainly): [Ref1][Ref2][Ref3]
| Upper GI bleeding | Lower GI bleeding | |
|---|---|---|
| Important causes |
|
|
| Rarer causes |
|
|
| Shared causes |
|
|
Be aware of some causes that may mimic GI bleeding: [Ref]
- Iron supplements cause stools to appear like melaena
- Certain food (e.g. beet root) causes stool to turn red
Some paediatric-specific causes of GI bleeding:
| Necrotising enterocolitis | In premature neonates
|
| Meckel’s diverticulum | In <2 y/o
|
| Intussusception | In 6-18 m/o
|
| Inflammatory bowel disease (ulcerative colitis > Crohn’s disease) | In adolescents |
Clinical Features
Presentation of upper vs lower GI bleeding: [Ref1][Ref2]
| Upper GI bleeding | Lower GI bleeding |
|---|---|
Common presentation:
Rarely, severe upper GI bleeding can cause haematochezia |
Presents as haematochezia (passage of fresh blood per rectum)
|
Non-specific features of bleeding:
- Tachycardia
- Orthostatic hypotension
- Pre-syncope
Assessment
Risk Assessment
NICE recommends the following scores to stratify patients:
- Glasgow-Blatchford score at first assessment (before endoscopy, Blatchford = Before), and
- Rockall score (complete) after endoscopy
The Glasgow-Blatchford score is used to assess the severity of upper GI bleeding and the need for intervention. Key components:
- Blood urea, haemoglobin, systolic BP, pulse
- Any melaena? Any syncope?
- Any history of hepatic disease? Any history of cardiac disease?
The Rockall score includes endoscopic findings, thus it can only be performed AFTER endoscopy. It is used to assess the risk of re-bleeding and mortality. Key components:
- Age
- Any hypotension? Any tachycardia?
- Any comorbidity? (heart failure, ischaemic heart disease, renal failure, liver disease, metastatic cancer)
- Endoscopic findings (diagnosis and stigmata of recent haemorrhage)
Work-Up
A standard work-up for acute GI bleed would include:
- CBC, U&E, LFT
- Coagulation tests – PT/INR, APTT
- Blood type and crossmatch
Main non-specific biochemical findings in GI bleed:
- ↓ Haemoglobin (but may be normal initially in acute bleeding)
- Acute bleeding gives a normocytic normochromic anaemia
- Chronic bleeding gives a microcytic hypochromic anaemia (iron deficiency)
- ↑ Urea with normal creatinine
- Mechanism (“protein meal”): digested blood → ↑ protein absorption → ↑ hepatic urea production → disproportionate rise in urea
- This classic pattern is only seen in upper GI bleeding, as blood is usually NOT digested in lower GI bleeding (so there is no increased protein absorption)
Management
Consider early discharge in those with a pre-endoscopy Blatchford score of 0.
Initial Management
A-E approach:
- Consider intubation to protect the airway (e.g. in patients with ongoing haematemesis and altered mental status)
- Gain IV access and start IV fluid resuscitation
- Transfuse and reverse anticoagulation accordingly (see below)
Transfusion Thresholds
Various transfusion thresholds:
| Component | Cut-off |
|---|---|
| Whole blood | Haemoglobin <70 g/L |
| Platelet | Platelet count <50 x 109 /L + actively bleeding |
| Fresh frozen plasma | PTProthrombin time (or INR) or APTTActivated partial thromboplastin time >1.5x normal |
| Cryoprecipitate | Fibrinogen level <1.5 g/L despite fresh frozen plasma |
| Recombinant factor VIIa | Only considered if all other methods have failed |
The transfusion thresholds in upper GI bleeding are broadly similar to standard blood product thresholds, except for a higher platelet target of 50 × 10⁹/L in the presence of active bleeding.
See the Blood Product Transfusion Thresholds article for more information.
Anticoagulation Reversal
| Anticoagulant | Reversal agent |
|---|---|
| Heparin | Protamine sulfate (fully effective for UFHUnfractionated heparin, but only partial reversal for LMWHLow molecular weight heparin) |
| Warfarin | Prothrombin complex concentratePCC (preferred to FFP) is the most vital reversal agent as it allows for rapid correction of vitamin-K dependent clotting factors. Vitamin K has a delayed onset of action and is not effective for immediate hemostasis in acute bleeding. However, it should be administered intravenously as an adjunct to sustain reversal and allow endogenous synthesis of clotting factors. (only consider fresh frozen plasma as 2nd line) + IV vitamin K |
| Dabigatran | Idarucizumab |
| Apixaban and rivaroxaban | Andexanet alfa |
There is no reversal agent for edoxaban (which is also a DOAC).
There are no reversal agents for antiplatelets (e.g. aspirin, clopidogrel). If patients take antiplatelet → withhold them.
Definitive Management
Definitive management is endoscopic haemostasis
- Unstable patients → resuscitate, then immediate endoscopy (once patient is stabilised
Airway protection and hemodynamic resuscitation are required prior to proceeding with endoscopy in the setting of massive ongoing hematemesis and shock.
) - Stable patients → endoscopy within 24 hours after admission
Endoscopic management depends on the source of bleeding.
Non-Variceal Bleeding
Offer one of the following for endoscopic haemostasis:
- Mechanical method (e.g. clip) +/- adrenaline
- Thermal coagulation with adrenaline
- Fibrin / thrombin with adrenaline
Post-endoscopy PPI is recommended if there are signs of recent or active bleeding at endoscopy (reduces risk of rebleeding and need for surgery)
- NICE specifically recommends AGAINST routine pre-endoscopic PPI (as it makes endoscopic bleeding less visible and does not improve key clinical outcomes like rebleeding, need for surgery and mortality)
Management of failed endoscopy or re-bleed:
- If patient is stable → consider repeat endoscopy
- If patient is unstable:
- 1st line: interventional radiology
- If not available promptly → urgent surgery
Variceal Bleeding
Pre-endoscopic management for ALL suspected variceal bleeding:
- Resuscitation (+/- transfusion as needed), and
- Terlipressin (stop after 5 days or after definitive haemostasis), and
- Prophylactic antibiotic
Definitive management: endoscopic interventions once patient is stablised:
- Oesophageal varices → band ligation
- Gastric varices → cyanoacrylate glue injection (chemical ligation)
If endoscopic measures failed → transjugular intrahepatic portosystemic shunt (TIPS) A radiological procedure where a mental stent is placed to create a shunt between the portal vein and hepatic vein (accessed via the jugular vein) Mechanism: blood bypasses the cirrhotic liver → reducing portal pressure
If re-bleeding occurs after successful endoscopic intervention → repeat endoscopic interventions (if the patient is stable).
NICE did not make any recommendations on the use of Sengstaken-Blakemore tube (a type of balloon tamponade), due to the risk of complications like aspiration and oesophageal perforation.
However, it may be used as a temporary measure if:
- The patient cannot be stabilised for endoscopic haemostasis, or
- Endoscopic haemostasis failed to control bleeding and before definitive therapy (e.g. TIPS) can be performed
Post-Acute Variceal Bleeding (Secondary Prophylaxis)
Offer all the following:
- Carvedilol
- Variceal band ligation every 4 weeks until eradication
- Surveillance upper GI endoscopy
References
NICE guideline Acute upper gastrointestinal bleeding in over 16s: management
NICE guideline Blood transfusion
MHRA Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents
British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis – part 2: decompensated cirrhosis