Upper Gastrointestinal Bleeding (UGIB)

Upper GI bleeding is one of the most common and high-risk gastro emergencies encountered in the NHS. It ranges from mild self-limiting bleeds to life-threatening haemorrhage requiring urgent escalation.

This guide focuses on what doctors actually need to know on the ward and on-call.

What counts as UGIB?

Bleeding from anywhere proximal to the ligament of Treitz (oesophagus, stomach, duodenum).

Typical presentations:

  • Haematemesis (fresh blood or coffee-ground vomit)
  • Melaena
  • Syncope / dizziness
  • Anaemia with no obvious source
  • Shock in severe cases

Common causes (think practically)

You don’t need a long textbook list — you need patterns.

Most common:

  • Peptic ulcer disease (gastric or duodenal)
  • Gastritis / oesophagitis
  • Mallory–Weiss tear
  • Varices (in cirrhosis)
  • Malignancy

On the ward, always ask:

Does this patient have chronic liver disease?

Because variceal bleeding changes everything.

First priority = Assess stability

Before thinking about diagnosis, always assess:

  • Airway (is the patient protecting it?)
  • Breathing
  • Circulation
    • BP
    • HR
    • Cap refill
    • Mental state
    • Urine output

Red flags:

  • Tachycardia
  • Hypotension
  • Confusion
  • Ongoing haematemesis
  • Hb dropping rapidly

These patients need urgent escalation.

Immediate management on the ward (what juniors should actually do)

If you’re the doctor called to see a suspected UGIB:

Do immediately:

  • A–E assessment
  • 2 wide-bore cannulas
  • Bloods: FBC, U&E, LFTs, coagulation, group & save
  • Crossmatch if concern about significant bleed
  • IV fluids if hypotensive
  • Keep patient nil by mouth
  • Start PPI (e.g. IV omeprazole)

If liver disease suspected:

  • Start terlipressin
  • Start IV antibiotics (e.g. ceftriaxone)
  • Early gastro involvement

When to escalate

You should escalate urgently if:

  • Ongoing haematemesis
  • Haemodynamic instability
  • Hb falling quickly
  • Known cirrhosis
  • NEWS ≥5
  • Concerned nursing staff

These patients often need:

  • Urgent endoscopy
  • HDU/ICU
  • Senior review

Never sit on a sick bleeder.

Endoscopy timing (realistic NHS practice)

  • Stable patient → endoscopy within 24 hours
  • Unstable / high-risk → endoscopy urgently after resuscitation
  • Variceal bleed → as soon as possible

Endoscopy is both diagnostic and therapeutic.

Variceal vs non-variceal (important conceptually)

You don’t need to memorise lists — just understand the logic.

Variceal bleed:

  • Portal hypertension
  • High risk of rebleeding
  • Needs terlipressin, antibiotics, urgent scope

Non-variceal bleed (e.g. ulcer):

  • Acid-related or mucosal disease
  • Managed with PPI + endoscopic therapy

Different mechanism → different management.

What juniors often miss (important learning points)

  • Delaying escalation in unstable patients
  • Forgetting antibiotics in suspected variceal bleed
  • Not checking coagulation
  • Underestimating melaena (“they look fine”)
  • Not documenting haemodynamic trends

UGIB patients can deteriorate suddenly.

Take-home concept

UGIB is not about memorising causes.
It’s about recognising severity early, stabilising well, and escalating appropriately.