Understanding Upper Gastrointestinal Bleeding: A Guide for Junior Doctors

Upper Gastrointestinal Bleeding: A Guide for Junior Doctors

Upper gastrointestinal bleeding (UGIB) is a critical condition that demands swift and accurate intervention. As junior doctors, mastering the art of taking a focused history, selecting the right investigations, and implementing a solid management plan is crucial.

History Taking: Key Questions

When you encounter a patient with UGIB, the history-taking process is your first step in determining the severity and potential causes of the bleeding. Here are the key questions to ask:

• Onset and Duration

  • "When did the bleeding start?"

  • "Has it been continuous or intermittent?"

• Volume and Characteristics

  • "How much blood have you noticed?"

  • "Was it bright red, dark, or resembling coffee grounds?"

• Associated Symptoms

  • "Have you experienced nausea or vomiting?"

  • "Have you had any abdominal pain or changes in bowel habits?"

  • "Any signs of dizziness or weakness?"

• Past Medical History

  • "Do you have a history of gastrointestinal disorders, such as peptic ulcers or liver disease?"

  • "Any history of bleeding disorders or use of anticoagulants?"

• Medication History

  • "Are you currently taking any medications, including over-the-counter drugs and supplements?"

  • "Have you recently started or stopped any medications?"

• Social History

  • "Do you consume alcohol, and if so, how much?"

  • "Do you smoke?"

• Family History

  • "Is there a family history of gastrointestinal conditions or bleeding disorders?"

These questions will help you assess the potential etiology and urgency of the bleeding, guiding your diagnostic and management approach.

Selecting the Right Investigations

After obtaining a thorough history, it’s time to choose the appropriate investigations. These will help confirm the diagnosis, assess the severity, and guide treatment.

• Initial Assessment

  • Vital Signs: Monitor blood pressure, heart rate, and respiratory rate to assess hemodynamic stability.

  • Complete Blood Count (CBC): Evaluate hemoglobin levels and platelet counts to gauge the extent of blood loss and overall blood health.

  • Electrolytes and Renal Function: Assess electrolyte imbalances and kidney function, which can be affected by significant bleeding.

• Endoscopy

  • Urgent Upper Endoscopy (Gastroscopy): This is often the most definitive test for diagnosing and managing UGIB. It allows direct visualization of the esophagus, stomach, and duodenum and enables therapeutic interventions like cauterization or banding of varices.

• Imaging

  • Abdominal Ultrasound: Useful in evaluating liver pathology or ascites that may contribute to bleeding.

  • CT Scan: Reserved for cases where endoscopy is not available or the diagnosis is unclear.

• Other Tests

  • Stool Occult Blood Test: Can help detect hidden bleeding if UGIB is suspected but not overtly visible.

Management Plan

The management of UGIB involves stabilizing the patient, addressing the underlying cause, and preventing future episodes. Here’s a structured approach:

• Initial Resuscitation

  • IV Fluids: Start with crystalloids to stabilize the patient’s blood volume.

  • Blood Transfusion: Administer packed red blood cells if hemoglobin levels are critically low or if the patient shows signs of hemodynamic instability.

  • Tranexamic Acid: Administer Tranexamix acid for major heamorrhage.

• Pharmacological Treatment

  • Proton Pump Inhibitors (PPIs): No evidence of any usefulness of PPIs.

  • Antibiotics: In cases of liver disease or suspected infections like spontaneous bacterial peritonitis, appropriate antibiotics should be started.

• Endoscopic Therapy

  • Coordinate with a gastroenterologist for urgent endoscopy if indicated. Endoscopic treatment may include cauterization of bleeding vessels or band ligation of varices.

• Addressing Specific Causes

  • Variceal Bleeding: Use vasoconstrictors such as octreotide/terlipressin and initiate balloon tamponade if necessary (Consult Senior).

  • Peptic Ulcer Disease: Ensure that H. pylori infection is addressed if present and manage with PPIs and possibly surgery if conservative measures fail.

• Preventive Measures

  • Avoid NSAIDs: Discontinue non-steroidal anti-inflammatory drugs if they are contributing to the bleeding.

  • Lifestyle Modifications: Counsel patients on avoiding alcohol and smoking, which can exacerbate gastrointestinal issues.