Acute upper gastrointestinal bleeding is haematemesis, coffee-ground vomiting or melaena from a source above the ligament of Treitz, and NICE CG141 is the guideline the CST clinical station expects you to quote. Its structure is simple: resuscitate by ABCDE, score the risk with Blatchford before endoscopy and full Rockall after it, get the endoscopy immediately after resuscitation if the patient is unstable and within 24 hours otherwise, and treat varices differently from ulcers from the first minute.

Key takeaways

  • NICE CG141 recommends the Blatchford score at first assessment and the full Rockall score after endoscopy; consider early discharge with a pre-endoscopy Blatchford score of 0
  • Endoscopy immediately after resuscitation for unstable patients with severe bleeding, and within 24 hours of admission for all other patients
  • Transfuse on the full clinical picture; platelets only if actively bleeding with a count under 50 x 10^9/L; FFP if actively bleeding with PT or APTT over 1.5 times normal; cryoprecipitate if fibrinogen stays under 1.5 g/L; prothrombin complex concentrate if bleeding on warfarin
  • Do not give a proton pump inhibitor before endoscopy for suspected non-variceal bleeding; give one after endoscopy if there are stigmata of recent haemorrhage
  • Suspected variceal bleeding gets terlipressin and prophylactic antibiotics at presentation; terlipressin stops after haemostasis or at 5 days
  • Unstable re-bleeding after endoscopic treatment goes to interventional radiology, and urgently to surgery if radiology is not promptly available

How does upper GI bleeding present, and how do I score it?

Upper GI bleeding presents with haematemesis, coffee-ground vomit or melaena, sometimes with syncope, and on a surgical ward it is often a stress ulcer in a sick post-operative patient or a known cirrhotic with varices. NICE CG141 asks for two scores: the Blatchford score at first assessment, and the full Rockall score once the endoscopy findings are known.

The Blatchford score uses the blood urea, the haemoglobin by sex, the systolic blood pressure, a heart rate of 100 or more, melaena, syncope, liver disease and cardiac failure. CG141 says to consider early discharge for a pre-endoscopy Blatchford score of 0; every other patient is admitted. Say the score as a number and say what it means.

What is the immediate management of upper GI bleeding, A to E?

Immediate management of upper GI bleeding is resuscitation by ABCDE with the airway protected from blood, because aspiration and hypovolaemia are what kill before the endoscopist arrives.

Airway and breathing

Sit the patient up if they are conscious, or lateral if they are not, with suction to hand. High-flow oxygen, respiratory rate and saturations. A patient with a reduced conscious level and active haematemesis needs an anaesthetist now, not after the endoscopy is booked.

Circulation

Two wide-bore cannulae, bloods including a crossmatch, full blood count, urea and electrolytes, liver function, clotting and a venous gas for lactate and haemoglobin. Give crystalloid while blood is coming and reassess after each bolus. CG141 says that massive bleeding is transfused with blood, platelets and clotting factors under the local massive bleeding protocol, and that decisions on transfusion rest on the full clinical picture because over-transfusion may be as damaging as under-transfusion.

Disability and exposure

Conscious level, capillary glucose, and then the examination that changes the plan: stigmata of chronic liver disease, a rectal examination for melaena, and the drug chart for anticoagulants, antiplatelets and NSAIDs.

What investigations does upper GI bleeding need?

Upper GI bleeding needs an endoscopy, and NICE CG141 sets its timing: immediately after resuscitation for unstable patients with severe acute bleeding, and within 24 hours of admission for everyone else. The blood tests are for the Blatchford score and the transfusion decisions rather than for the diagnosis.

In practice the investigation the panel wants named is the one that is time-critical. An erect chest radiograph is only relevant if you suspect perforation, and a CT angiogram is for the patient with ongoing bleeding when endoscopy has failed or cannot find the source. Neither should delay the resuscitation or the call to the endoscopist.

What is the definitive management of upper GI bleeding?

Definitive management of upper GI bleeding is endoscopic haemostasis, with the drugs and the fallback decided by whether the bleeding is variceal or not.

Non-variceal bleeding

NICE CG141 recommends against acid-suppression drugs before endoscopy in suspected non-variceal bleeding. After endoscopy, patients with stigmata of recent haemorrhage get a proton pump inhibitor. Patients at high risk of re-bleeding may have a repeat endoscopy, and patients who re-bleed are offered repeat endoscopy with a view to further endoscopic treatment or emergency surgery.

Unstable patients who re-bleed after endoscopic treatment are offered interventional radiology, and referred urgently for surgery if interventional radiology is not promptly available. Low-dose aspirin for secondary prevention is continued once haemostasis is achieved, and continuing clopidogrel is discussed with the relevant specialist.

Variceal bleeding

Suspected variceal bleeding gets terlipressin at presentation, stopped after definitive haemostasis or after 5 days, and prophylactic antibiotics at presentation. Oesophageal varices are band ligated; TIPS is considered if banding does not control them. Gastric varices are injected with N-butyl-2-cyanoacrylate, and TIPS is offered if that fails.

Blood products

  • Platelets: only if actively bleeding and the count is under 50 x 10^9/L; not for a stable patient who is not bleeding
  • Fresh frozen plasma: if actively bleeding with a prothrombin time, INR or APTT over 1.5 times normal
  • Cryoprecipitate: if fibrinogen stays under 1.5 g/L despite fresh frozen plasma
  • Prothrombin complex concentrate: for patients on warfarin who are actively bleeding

When do I escalate upper GI bleeding, and to whom?

Escalate upper GI bleeding to the surgical registrar and the on-call endoscopist at the same time, and involve the anaesthetist and critical care for any patient who is haemodynamically unstable or cannot protect their airway. CG141 makes the unstable patient's endoscopy immediate after resuscitation, so the call to the endoscopist is part of the resuscitation, not a follow-on.

Say the triggers you would use: ongoing haematemesis, a rising lactate, a falling haemoglobin despite transfusion, or re-bleeding after endoscopy. Name the massive haemorrhage protocol and who activates it. If the patient is a known cirrhotic, say that the gastroenterology team is told at presentation because the varices need terlipressin and antibiotics from you now.

What is the interviewer listening for in an upper GI bleed scenario?

  • Resuscitation first, with the airway named as the risk in a vomiting, drowsy patient
  • Blatchford before endoscopy and Rockall after, and the discharge rule for a score of 0
  • The endoscopy timing stated as CG141 gives it: immediately if unstable, within 24 hours otherwise
  • No PPI before endoscopy for non-variceal bleeding, with the reason that it is the guideline rather than a preference
  • Varices treated differently from the start: terlipressin, antibiotics, the gastroenterology team
  • The transfusion thresholds said as numbers, and the fallback chain: repeat endoscopy, radiology, surgery

What are the common mistakes with upper GI bleeding?

The commonest mistake with upper GI bleeding at interview is to open with a proton pump inhibitor, which CG141 recommends against before endoscopy in non-variceal bleeding. The second is to transfuse to a number rather than to the clinical picture.

  • Ordering the endoscopy for the morning list in a patient who is still hypotensive
  • Giving platelets to a stable, non-bleeding patient with a low count
  • Forgetting terlipressin and antibiotics in a patient with known liver disease
  • Stopping low-dose aspirin permanently after haemostasis in a patient with a coronary stent
  • Not putting the anaesthetist in the room for a drowsy patient with active haematemesis

How this comes up at the CST interview

The CST management and clinical station sets upper GI bleeding as a post-operative patient with melaena and a heart rate over 100, or a cirrhotic with haematemesis, and asks for your first five minutes, your scoring and your escalation. Quote NICE CG141 by number, give the endoscopy timing and the transfusion thresholds, and name the endoscopist and anaesthetist as calls made during resuscitation. coresurgeryinterview scores a version of this scenario among its 299 questions with AI-marked spoken practice, at /Question-Bank/Sample-Questions.