Upper Gastrointestinal Bleed

You are the General Surgery CT1 and are asked to see a 40 year old patient who has been admitted on the general surgery ward for investigation of abdominal pain. He has been taking regular ibuprofen. The nurse bleeps you as the patient is vomiting fresh blood.

Example answer introduction

In this scenario, I would be most concerned about a possible upper gastrointestinal bleed.  As he is actively bleeding there is a potential risk of haemorrhagic shock and therefore I would attend immediately.  I would assess this patient using an A-E approach according to the CCRISP algorithm followed by a focused history and examination. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions and escalate to the general surgery registrar.

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications - anticoagulants, antiplatelets, steroids

  • Past medical history –history of alcohol excess, history of peptic ulcer disease

  • Last meal

  • Events leading up to this point – how much NSAIDs and for how long, is the patient also on steroids

Examination

  • Abdominal Examination:

    • Look for signs of liver diseas and portal hypertension e.g. spider spider naevi, portosystemic shunting and bruising – these may suggest variceal haemorrhage which needs specific treatment

  • Examine for signs of acute substantial blood loss and shock e.g. hypotension, tachycardia and  tachypnoea hypertension

 

Investigations

  • Bloods: FBC, U&E, LFTs, clotting, cross match, lactate

    • FBC may be normal immediatiely after an acute bleed but will fall after haemodilution occurs

    • May be evidence of anaemia – suggests more chronic blood loss

    • May have deranged coagulation profile in liver disease

  • Imaging– Chest X-ray if patient is stable looking for evidence of pneumoperioneum

Initial management

The patient has no history of liver disease or alcohol excess and therefore you do not suspect a variceal bleed. Your main differential diagnosis is a bleeding peptic ulcer. 

How would you manage this once the patient is resuscitated and stabilised?

  • Resuscitation as above 

  • Analgesia

  • NG tube to monitor bleeding and prevent aspiration

  • Urinary catheter to monitor urine output

  • Contact general surgical registrar as may need definitive treatment

    • Endoscopy - detect and treat bleeding

      • Aim is to identify bleeding point, arrest the bleeding and prevent recurrence

      • Bleeding spontaneously ceases in 90% of patients

      • Endoscopy can identify site of bleeding in 80-90% of cases

    • May need angiography if cannot identify bleeding point

      • Nb: can only detect active bleeding of greater than 1ml/min

      • In these cases selective embolisation can be performed to stop bleeding and avoid surgery

    • Surgical management

      • Indicated if endoscopic therapy is unable to control the bleeding. 

      • Type of operation will depend on site of bleeding ulcer and comorbidity of patient 

      • Bleeding gastric ulcer should always be biopsied

      • In young fit patients, ulcer should be excised completely with small wedge resection

      • In elderly patients or those with significant comorbidity – under-running of the ulcer may be preferable

  • Once tolerating oral fluids – H. pylori eradication should be initiated

Escalation

Consider discussion with:

  • ​General Surgical registrar

  • Gastroenterology – may be required for endoscopy – depends on local trust escalation policy

  • Radiologist for angiography

  • Anaesthetics and theatres – if surgery required

  • Critical care

Useful Resources

NICE - Acute upper gastrointestinal bleeding in over 16s: management

Glasgow Blatcford Score

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.

Example questions you may encounter during the station

Q1 - What endoscopic techniques can be used to arrest bleeding?

Adrenaline (epinephrine) 1:10,000 injection and application of heater probes and clips. 

 

Q2 - What features of the ulcer are associated with further bleeding?

  • Bleeding from the ulcer base

  • Presence of a visible vessel 

  • adherent clot overlying the ulcer 

Q3 - What are the common causes of an upper GI bleed?

  • Table 13.2 Causes of upper gastrointestinal bleeding.

  • Peptic ulceration  - 50%

  • Mucosal lesions including gastritis, duodenitis and erosions - 30%

  • Duodenitis and erosions

  • Mallory-Weiss tear - 5–10%

  • Varices 5–10%

  • Reflux oesophagitis 5%

  • Angiodysplasia 2%

  • Carcinoma  - Uncommon

  • Aortoduodenal fistula - Uncommon

  • Dieulafoy syndrome (rupture of a large tortuous submucosal artery ormally found in the body of the stomach) - Rare

  • Coagulopathies - Uncommon

Q4 - How might an upper GI bleed present?

  • Actively vomiting blood

  • Malaenia 

Q5 - What risk scoring systems for upper GI bleed do you know?

core surgical training interview

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