These patients have the potential to become haemodynamically unstable extremely quickly; try to avoid delays in reviewing them. In-hospital mortality is around 10%. If they are unwell then assess them using A-E and a SAMPLE history and get senior help quickly if you are concerned. Depending on your hospital this may be via the arrest team, medical emergency team, critical care outreach or contacting the medical registrar. Most hospitals will have an upper GI bleed protocol and a major haemorrhage protocol on the intranet; this may also be printed and on the arrest trolleys. For stable patients then clerk them as normal, but be aware of the risk of rapid decompensation

Common causes of upper GI bleed (coffee ground vomiting) are ulcers, varices, malignancy, Mallory-Weiss tear

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Initial assessment

A – Airway compromise can be due to vomiting or decreased consciousness. Support their airway, give high flow oxygen and get urgent help
B – Check sats, resp rate and auscultate their chest. Tachypnoea is one of the early signs of shock
C – Check heart rate, blood pressure and capillary refill. Get IV access (ideally, 2 wide bore cannulae as proximally as possible, but this can be difficult with a shocked patient). Send blood for FBC, U&Es (raised urea suggests digestion of blood), LFTs, VBG, clotting and 2 group and saves. Look at the vomit- fresh blood, clots, coffee grounds? Treat hypotension as per your local protocol, this often means IV fluids while waiting for urgent blood. Consider catheterising.
D – Check AVPU, pupils and glucose
E – Check temperature, abdominal exam, look for other sites of lost blood, do a PR looking for fresh blood or melaena. Keep the patient nil by mouth.

SAMPLE history

• Signs and symptoms
• Allergies
• Medications (stop anticoagulants and consider reversing, if on warfarin check INR)
• Past medical history
• Last oral intake (keep the patient nil by mouth)
• Events leading up to presentation (eg recent NSAIDs/steroids/ETOHXS)

Risk assessment

The Glasgow-Blatchford score is used pre endoscopy to assess the urgency of endoscopy; local rules will vary but generally if the patient scores 0 they can be listed for outpatient endoscopy, 1-5 prompt inpatient endoscopy and 6+ needing urgent scoping. Rockall scores are used post endoscopy to risk stratify for morbidity and mortality

Hypovolaemic shock can be categorized from 1-4 depending on severity; this scoring system can be complicated and difficult to remember. It’s much easier to compare heart rate and systolic blood pressure- if HR is higher than SBP then the patient is probably shocked.

Resuscitation

Patients should be adequately resuscitated before transfer to endoscopy. If they are actively bleeding, deranged clotting/low platelets or are haemodynamically unstable, consider transfusing blood as per the local major haemorrhage protocol. Activating this varies from hospital to hospital, but usually involves someone calling the lab & then being the allocated person to liaise with the lab regarding each blood product. Depending on the underlying coagulopathy, treatment can include Vitamin K, prothrombin complex, FFP and cryoprecipitate.

Consider whether this may be a variceal bleed if the patient has any signs of chronic liver disease or LFTs & deranged liver synthetic function that suggests this (raised INR, low albumin). If the bleeding is thought to be variceal then also give prophylactic antibiotics. Consider terlipressin, but this is a potent vasoconstrictor so can cause acute limb ischaemia or a MI (baseline ECG required). Therefore give terlipressin with senior approval. If a non-variceal bleed is suspected then check local protocol regarding PPIs, many trusts advise not to as this can mask the bleeding site

Control of bleeding

This predominantly via endoscopic methods – OGD allows banding of varices, injection of adrenaline, clipping of ulcers etc. Other methods include placement of a Sengstaken-Blakemore tube which applies pressure to the bleeding sites; surgical approach to oversew bleeding areas or TIPS (transjugular intrahepatic portosystemic shunt) which bypasses the hepatic circulation reducing variceal pressure.

Do not consent for an OGD unless you have been trained to do so- complications can be significant

Return to the ward

Following a patient’s return to the ward check carefully through the endoscopy report – the endoscopist will often have specified how long they want a patient NBM, on certain meds and when a re-scope should be booked for.

If asked to review an unwell patient post endoscopy then consider further bleeding, perforation and infection as differentials. Keep them NBM until senior r/v and reassess as per above

Evidence Based Practice Tip

It is not uncommon to get called to a patient who has had coffee ground vomiting during out of hours shifts.

A retrospective observational study from Aberdeen published in 2020 found that there was a roughly 80% probability that coffee ground vomiting was due to a cause that was not amenable to endoscopic treatment.

With this in mind, when asked to see someone with coffee ground vomiting, look at the risk factors for things like ulcers or varices, and whether there is any other clinical evidence of bleeding such as melaena.

The paper: Schneider JR et al. Is coffee ground vomiting important? Findings from a large bleeding unit database and outcomes at 30 days. Eur J Gastroenterol Hepatol. 2020 Jul;32(7):797-803. doi: 10.1097/MEG.0000000000001701. 

A deeper dive: https://www.beffy.org/coffee-ground-vomiting-how-worried-shoudl/

Further reading

• NICE CG 141 Acute upper gastrointestinal bleeding in over 16s: management
• Patient.info – UGIB & Rockall Score

By Dr Stef Wischhusen, BDS (Hons), MFDS RCS Ed, MbChB (Hons)