Upper Gastrointestinal Bleed (UGIB)
Emergency assessment, risk stratification, and management of upper GI haemorrhage
Upper gastrointestinal bleeding is a medical emergency arising from the oesophagus, stomach, or duodenum. Rapid risk stratification using the Glasgow-Blatchford Score determines which patients require urgent hospital admission, while the Rockall Score — calculated after endoscopy — predicts rebleeding risk and mortality. Immediate resuscitation, early endoscopy within 24 hours, and targeted pharmacological therapy are the cornerstones of management.
What is UGIB?
Upper gastrointestinal bleeding (UGIB) refers to blood loss from anywhere in the upper gastrointestinal tract — from the oesophagus, stomach, or duodenum. It is a serious medical emergency with a mortality rate of approximately 10%. The most common cause is peptic ulcer disease, which accounts for up to 50% of cases. Other important causes include oesophageal varices (particularly in patients with liver disease), Mallory-Weiss tears (from repeated vomiting), erosive gastritis, and oesophagitis. Medications — particularly NSAIDs, aspirin, anticoagulants, and steroids — significantly increase the risk of UGIB.
Recognising UGIB
The most recognisable presentations are haematemesis (vomiting blood or coffee-ground material) and melaena (dark, tarry, foul-smelling stools caused by digested blood). If bleeding is very brisk, bright red blood may appear in the stool (haematochezia). Patients may also present with dizziness, fainting, or collapse from blood loss. On examination, tachycardia and hypotension are warning signs of significant haemodynamic compromise and require immediate action. Any patient with suspected UGIB should be assessed urgently in hospital.
Risk scores and endoscopy
The Glasgow-Blatchford Score (GBS) is calculated at presentation using blood urea, haemoglobin, systolic blood pressure, heart rate, and clinical features. A score of zero identifies patients who may be safely managed as outpatients — everyone else requires hospital admission. Endoscopy (OGD — oesophagogastroduodenoscopy) should be performed within 24 hours for all admitted patients, or within 12 hours for those who are haemodynamically unstable or where variceal bleeding is suspected. The Rockall Score, calculated after OGD, uses the endoscopic findings alongside clinical data to predict rebleeding and mortality risk.
Treatment
Initial management focuses on resuscitation: two large-bore IV cannulae, IV fluid replacement, and blood transfusion if haemoglobin falls below 70 g/L (80 g/L in cardiovascular disease). For non-variceal bleeding, high-dose IV PPI (omeprazole 80 mg bolus then 8 mg/hour infusion) is given after endoscopic haemostasis for high-risk ulcers. For variceal bleeding, terlipressin and prophylactic antibiotics are started immediately and urgent band ligation is performed at endoscopy. NSAIDs and anticoagulants are reviewed and temporarily withheld. H. pylori should be tested and eradicated if positive.
Recovery and prevention
After discharge, patients with peptic ulcer disease should continue a PPI and confirm H. pylori eradication with a breath test 4 weeks after completing eradication therapy. NSAIDs should be avoided where possible — if essential, a PPI must be co-prescribed. Anticoagulation can typically be restarted 7 days after haemostasis, following specialist discussion. For variceal bleeding, long-term propranolol and repeat endoscopic band ligation sessions every 2–4 weeks until varices are obliterated are essential for secondary prevention. Alcohol cessation is critical in alcohol-related cases.