GI bleeding assessment and resuscitation

Upper and Lower Gastrointestinal Bleeding & Peptic Ulcer Disease

Acute gastrointestinal (GI) haemorrhage is a frequent, life-threatening clinical emergency encountered in Australian emergency departments and inpatient wards. Mastery of rapid haemodynamic triage, risk score stratification, target-driven resuscitation, differentiation of variceal versus non-variceal aetiologies, and definitive diagnostic algorithms is essential for the AMC examination.

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Clinical Presentation and Initial Triage

GI bleeding is anatomically divided by the suspensory ligament of the duodenum (ligament of Treitz):

• Upper GI Bleeding (UGIB): Arises proximal to the ligament of Treitz (oesophagus, stomach, or duodenum).
• Lower GI Bleeding (LGIB): Arises distal to the ligament of Treitz (jejunum, ileum, colon, rectum, or anus).

Hallmark Clinical Manifestations

• Haematemesis: Clinical Description: Vomiting of bright red blood or fresh blood clots; Suspected Source: Active, brisk upper GI bleeding (peptic ulcer, oesophageal varices, Mallory-Weiss tear)
• 'Coffee-Ground' Vomitus: Clinical Description: Dark brown, granular vomitus resembling coffee grounds; Suspected Source: Slower or ceased upper GI bleeding altered by gastric hydrochloric acid to haematin
• Melaena: Clinical Description: Black, tarry, foul-smelling, sticky stools; Suspected Source: Upper GI bleeding (requires $\ge 50\text{ mL}$ of blood and $\ge 14\text{ hours}$ of gut transit time); occasionally right-sided colonic bleed with slow transit
• Haematochezia: Clinical Description: Passage of fresh red or maroon blood and clots per rectum; Suspected Source: Lower GI bleeding in $> 85\%$ of cases; in $10-15\%$, signifies massive, life-threatening upper GI bleeding with rapid intestinal transit and haemodynamic collapse

The Blood Urea to Creatinine Ratio

• Urea and creatinine: Urea may rise disproportionately after digestion of upper-GI blood, but dehydration and kidney disease also affect it. Do not compare an unconverted mmol/L urea value with a micromol/L creatinine value using a memorised ratio.

1. Digestion and intestinal reabsorption of blood protein breakdown products (amino acids) in the small bowel.
2. Prerenal azotaemia secondary to intravascular hypovolaemia and reduced renal cortical perfusion.

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Resuscitation Principles

Resuscitation takes priority over diagnostic investigations. Immediate priorities follow a structured Airway, Breathing, Circulation (ABC) approach:

1. Airway Protection: Massive haematemesis carries an imminent risk of fatal pulmonary aspiration. Endotracheal intubation is mandatory before endoscopy in patients with persistent vomiting of blood, severe agitation, or depressed consciousness (Glasgow Coma Scale $\le 8$ or hepatic encephalopathy).
2. Venous Access: Insert two large-bore peripheral cannulae (14G or 16G) into the antecubital fossae. Central venous access should not delay peripheral peripheral cannulation.
3. Intravenous Fluid Resuscitation: Infuse balanced crystalloids (warmed Hartmann's solution or $0.9\%$ sodium chloride) in aliquots of $500\text{ mL}$ to restore circulating volume. In cirrhotic patients with portal hypertension, avoid over-transfusion and excessive fluid administration, which increases portal venous pressure and exacerbates variceal bleeding.
4. Restrictive Transfusion Strategy: Landmark randomized controlled trials (Villanueva et al.) have established that a restrictive red cell transfusion threshold significantly improves survival in acute upper GI bleeding:
   • Transfusion: Around 70 g/L is a common restrictive threshold in stable patients, often aiming for 70–90. Treat haemorrhagic shock clinically without waiting for a haemoglobin threshold; cardiac ischaemia and individual circumstances can change the target.
   • Cardiovascular Disease Exception: In patients with active coronary artery disease, acute myocardial ischaemia, or severe symptomatic peripheral vascular disease, maintain a higher target haemoglobin of $80-90\text{ g/L}$ (transfusion trigger $< 80\text{ g/L}$).
   • Liberal transfusion strategies (target $> 90-100\text{ g/L}$) paradoxically increase mortality and rebleeding rates by elevating splanchnic pressures and disrupting immature haemostatic plugs.
5. Antithrombotics: Review bleeding severity and thrombosis risk. Major warfarin bleeding warrants IV vitamin K plus PCC under protocol; Beriplex AU is four-factor whereas replaced Prothrombinex-VF was three-factor. DOAC reversal depends on the agent, timing, renal function and availability. Aspirin for secondary prevention is often continued or restarted promptly; interruption after a recent stent requires cardiology input. Correct platelets/fibrinogen as indicated by the bleeding protocol.

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Risk Stratification Scoring Systems

Evidence-based scoring tools distinguish high-risk patients needing intensive care and emergent endoscopy from low-risk patients suitable for outpatient management.

• Timing of Use: Glasgow-Blatchford Score (GBS): Pre-endoscopy (at initial emergency triage); Rockall Score: Post-endoscopy (complete score incorporates endoscopic findings)
• Variables Assessed: Glasgow-Blatchford Score (GBS): Blood urea, haemoglobin, systolic BP, pulse, melaena, syncope, hepatic disease, cardiac failure; Rockall Score: Clinical: Age, shock (BP, HR), comorbidities; Endoscopic: Diagnosis, stigmata of recent haemorrhage.
• Scoring Range: Glasgow-Blatchford Score (GBS): $0$ to $23$; Rockall Score: $0$ to $11$ (initial clinical component $0-7$)
• Low-Risk Cutoff: Glasgow-Blatchford Score (GBS): Score 0 to 1: Mortality $< 0.5\%$; minimal intervention risk. Suitable for discharge and outpatient workup.; Rockall Score: Score $\le 2$: Low risk of rebleeding ($< 5\%$) and mortality ($< 1\%$).
• High-Risk Cutoff: Glasgow-Blatchford Score (GBS): Score $\ge 2$: Requires inpatient admission, resuscitation, and inpatient endoscopy within 24 hours.; Rockall Score: Score $\ge 8$: High rebleeding risk ($> 40\%$) and mortality ($> 25\%$).

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Primary references (checked 7 October 2026): National Blood Authority PCC transition.