10.5 Acute Upper Gastrointestinal Bleeding: Risk Scores, Ulcer & Variceal Haemorrhage

Acute gastrointestinal haemorrhage and colonic neoplasia are quintessential emergencies in acute internal medicine. Candidates must master resuscitation parameters, endoscopic risk stratification, targeted endoscopic and pharmacological haemostasis for non-variceal and variceal bleeding, diverticular disease staging, and the genetic architecture of hereditary colorectal cancer syndromes.

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1. Acute Upper Gastrointestinal Bleeding (UGIB) & Risk Stratification

Acute upper GI bleeding (bleeding originating proximal to the suspensory ligament of Treitz at the duodenojejunal flexure) carries an overall in-hospital mortality of 8–10%. Common aetiologies comprise peptic ulcer disease (~50%), oesophageal and gastric varices (~10–15%), Mallory-Weiss tears (~5–10%), erosive gastroduodenitis (~10%), and upper GI malignancies (~3–5%).

Resuscitation & Restrictive Transfusion Policy

• Airway, Breathing, Circulation (A-B-C): High-flow oxygen if hypoxic; protect the airway in patients with massive haematemesis or altered mental status (early elective endotracheal intubation prevents fatal aspiration). Insert two large-bore peripheral IV cannulae (14–16 gauge) and commence crystalloid fluid resuscitation.
• Restrictive Red Blood Cell Transfusion Strategy: Landmark randomized trials (TRIGGER and RESTRICT) demonstrate that liberal transfusion strategies increase portal and splanchnic venous pressures, overcome physiological vasoconstriction, dislodge fragile platelet-fibrin clots, and significantly increase rebleeding rates and overall mortality.
  • Standard Threshold: Transfuse packed red blood cells only when haemoglobin falls below 70 g/L, targeting a post-transfusion haemoglobin of 70–80 g/L.
  • Cardiovascular Disease Threshold: In patients with active acute coronary syndromes, severe pre-existing ischaemic heart disease, or symptomatic cerebral vascular disease, a higher transfusion threshold of <80 g/L is applied, targeting a post-transfusion haemoglobin of 80–90 g/L.
• Coagulopathy Management:
  • Platelet transfusion is indicated if active bleeding occurs with a platelet count <50 x 10^9/L.
  • Fresh frozen plasma (FFP) is administered if the prothrombin time ratio / INR >1.5 or fibrinogen <1.5 g/L (or cryoprecipitate if fibrinogen remains low despite FFP).
  • In patients taking warfarin with life-threatening bleeding, administer four-factor prothrombin complex concentrate (PCC) (25–50 units/kg) alongside intravenous vitamin K (5–10 mg) to achieve immediate, sustained reversal.
  • For direct oral anticoagulants (DOACs): administer idarucizumab for dabigatran reversal, or andexanet alfa (or high-dose 4-factor PCC if unavailable) for factor Xa inhibitors (apixaban, rivaroxaban).

Risk Stratification: Pre-Endoscopy vs Post-Endoscopy

The Glasgow-Blatchford Score (GBS)

The Glasgow-Blatchford Score is a validated, sensitive scoring tool calculated strictly prior to endoscopy at presentation. It determines the requirement for urgent clinical intervention (blood transfusion, endoscopic therapy, or surgical haemostasis) and identifies very low-risk patients who can be safely managed in the outpatient setting without admission.

• Clinical Decision Rules:
  • GBS Score = 0: Extremely low risk (<0.5% mortality; essentially 0% need for intervention). Patients can be safely discharged directly from the emergency department for outpatient investigation.
  • GBS Score >=1: Inpatient admission and diagnostic gastroscopy indicated.
  • GBS Score >=6: Associated with high intervention rates (>50%) and high mortality, warranting urgent resuscitation and early endoscopy within 12–24 hours.

The Rockall Score

Unlike the GBS, the complete Rockall Score assesses post-procedure mortality and rebleeding risk by incorporating patient clinical variables (age, shock, comorbidity) with endoscopic findings (endoscopic diagnosis and stigmata of recent haemorrhage). A complete score <3 carries low risk of rebleeding and mortality (<5%), whereas a score >=8 confers an ominous mortality risk exceeding 40%.

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2. Non-Variceal Upper GI Bleeding: Peptic Ulcers

Endoscopic Timing & The Forrest Classification

Endoscopy should be performed within 24 hours of presentation in all admitted patients, and within 12 hours in haemodynamically unstable patients following initial resuscitation. The Forrest Classification grades the risk of rebleeding in peptic ulcer disease and dictates whether endoscopic therapy is mandatory:

Endoscopic Haemostatic Modalities

• High-Risk Lesions (Forrest Ia, Ib, IIa): Guidelines from NICE and ESGE strictly mandate endoscopic dual therapy. Dilute adrenaline injection (1:10,000, which provides local volume tamponade and transient alpha-1 vasoconstriction) must always be combined with a definitive secondary mechanical or thermal modality:
  • Mechanical: Through-the-scope haemostatic clips (TTS clips) or over-the-scope clips (OTSC), which achieve permanent mechanical vascular occlusion.
  • Thermal: Contact thermal coagulation (heater probe, bipolar electrocoagulation) or non-contact thermal therapy (argon plasma coagulation).
  • Critical Rule: Adrenaline monotherapy is strictly contraindicated and unacceptable because local vasoconstriction dissipates within 15–20 minutes, leading to unacceptably high rebleeding rates (>30%).
• Pharmacological Therapy:
  • Post-Endoscopic IV PPI Infusion: For high-risk ulcers successfully treated endoscopically (Forrest Ia–IIa), administer high-dose intravenous PPI: an 80 mg intravenous bolus of omeprazole/pantoprazole, followed by a continuous infusion of 8 mg/hour for 72 hours (or 40 mg IV twice daily). Acid suppression maintaining intragastric pH >6.0 irreversibly inactivates pepsin and prevents pepsin-mediated fibrin clot lysis, preserving platelet aggregation.
  • Management of Rebleeding: Occurs in 10–15% of high-risk ulcers. First-line management is repeat urgent endoscopy. If endoscopic haemostasis fails a second time, immediately proceed to transcatheter arterial embolisation (TAE) via interventional radiology, or emergency surgical under-running of the bleeding vessel.

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3. Variceal Upper GI Bleeding

Variceal haemorrhage arises from ruptured gastro-oesophageal varices secondary to clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] >=12 mmHg, normal <=5 mmHg). It carries a formidable 6-week mortality of 15–20%.

Acute Emergency Management Bundle

Treatment must be initiated immediately upon clinical suspicion of variceal bleeding, before the patient is transferred to the endoscopy suite:

1. Pre-Endoscopic Vasoactive Therapy: Administer immediately:
   • Terlipressin: Synthetic vasopressin analogue (initial dose 2 mg IV bolus 4-hourly, reduced to 1 mg 4-hourly once haemostasis is secured, continued for up to 48–72 hours). Induces selective splanchnic vasoconstriction via V1 vascular receptors, reducing portal blood flow and lowering HVPG. Adverse effects: Peripheral ischaemia, hyponatraemia, and coronary vasoconstriction (use cautiously in ischaemic heart disease).
   • Octreotide / Somatostatin: Somatostatin analogue (50 mcg IV bolus followed by 50 mcg/hour continuous infusion). Alternative to terlipressin with fewer ischaemic side effects.
2. Prophylactic Broad-Spectrum Antibiotics: Administer intravenous Ceftriaxone 1 g once daily (or oral/IV ciprofloxacin) for 5–7 days. Up to 50% of cirrhotic patients with UGIB develop spontaneous bacterial peritonitis (SBP), pneumonia, or bacteremia; antibiotic prophylaxis dramatically reduces bacterial translocation, rebleeding rates, and overall in-hospital mortality.
3. Restrictive Transfusion: Target haemoglobin 70–80 g/L. Over-transfusion expands plasma volume, elevates portal venous pressure, and precipitates early catastrophic rebleeding.

Endoscopic Intervention (Within 12 Hours)

• Oesophageal Varices: Endoscopic Variceal Band Ligation (EVBL) is the intervention of choice. Elastic bands are placed around variceal columns starting at the gastro-oesophageal junction and extending proximally. Endoscopic sclerotherapy is reserved only for when banding is technically impossible due to severe active haemorrhage obscuring the endoscopic field.
• Gastric Varices: Fundal varices (Gastro-Oesophageal Varices type 2 [GOV2] or Isolated Gastric Varices type 1 [IGV1]) cannot be banded safely due to high rebleeding when bands slough off large vessels. Managed with endoscopic injection of N-butyl-2-cyanoacrylate (tissue adhesive / "superglue") mixed with Lipiodol, which polymerizes instantly upon contact with blood, obliterating the variceal lumen.

Salvage & Decompression Therapies

• Balloon Tamponade (Sengstaken-Blakemore Tube): For massive, uncontrolled variceal bleeding refractory to medical and endoscopic therapy. The tube possesses a gastric balloon (inflated with 200–250 mL of air and retracted against the cardia) and an oesophageal balloon (inflated to 30–45 mmHg if bleeding persists). Serves purely as a temporary bridging measure (maximum duration 24 hours) to prevent fatal exsanguination while definitive therapy is arranged; prolonged inflation causes oesophageal ischaemic necrosis and perforation.
• Transjugular Intrahepatic Portosystemic Shunt (TIPS): An artificial low-resistance tract created radiologically between the inflow portal vein and the outflow hepatic vein using an expanded polytetrafluoroethylene (ePTFE)-covered stent. Indications include:
  • Emergency Rescue TIPS: Failure of medical and endoscopic haemostasis.
  • Early / Pre-emptive TIPS (within 72 hours): In high-risk patients (Child-Pugh Class C, or Child-Pugh Class B with active bleeding at index endoscopy), early TIPS significantly reduces treatment failure and mortality.
• Secondary Prophylaxis: Repeat EVBL every 2–4 weeks until complete variceal eradication, coupled with lifelong non-selective beta-blockers (propranolol or carvedilol, which reduce cardiac output via beta-1 and provoke unopposed alpha-1 splanchnic vasoconstriction via beta-2 blockade).

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