SCE Gastroenterology: Mastering Upper GI Bleed Guidelines

As medical professionals, managing acute upper gastrointestinal (UGI) bleeding is a high-stakes scenario that demands rapid, accurate assessment and intervention. For those preparing for the Specialty Certificate Examination (SCE) in Gastroenterology, a thorough understanding of the current guidelines for UGI bleed management is not just theoretical knowledge, but a cornerstone of safe and effective practice. This blog post, drawing on UK national guidelines (e.g., British Society of Gastroenterology - BSG) and my experience as an examiner, will equip you with the essential knowledge to excel.

The Urgency of Upper GI Bleed

Upper GI bleeding, defined as haemorrhage originating proximal to the ligament of Treitz, is a common medical emergency with significant morbidity and mortality. Causes range from peptic ulcer disease (most common) to variceal haemorrhage, Mallory-Weiss tears, oesophagitis, and malignancy. The SCE will test your ability to differentiate these, risk stratify patients, and apply appropriate management strategies.

1. Initial Assessment and Resuscitation: The ABCDE Approach

First principles are paramount. Your initial approach must always follow the ABCDE algorithm:

• Airway: Protect the airway, especially in actively vomiting or encephalopathic patients.

• Breathing: Assess respiratory status. Oxygen supplementation may be needed.

• Circulation: This is critical.

  • Rapid assessment of haemodynamic stability: Look for signs of shock (tachycardia, hypotension, cool peripheries, decreased urine output, altered mental status).

  • Secure large-bore intravenous access: At least two peripheral cannulae (14/16G).

  • Fluid resuscitation: Intravenous crystalloids (e.g., 0.9% saline) to restore circulating volume. Be cautious in patients with known cardiac failure.

  • Blood transfusion: Initiate early if there are signs of shock or significant anaemia (haemoglobin < 70 g/L, or < 80 g/L in patients with cardiovascular comorbidity).

  • Investigations: Immediate FBC, U&Es, LFTs, coagulation screen (INR, APTT), and cross-match 4-6 units of blood.

• Disability: Assess neurological status (GCS) and address any altered consciousness.

• Exposure: Examine the patient thoroughly for stigmata of chronic liver disease, abdominal tenderness, or other relevant findings.

2. Risk Stratification: Guiding Decisions

Accurate risk stratification informs urgency of endoscopy and intensity of management. The Glasgow-Blatchford Score (GBS) is highly recommended pre-endoscopy for predicting the need for intervention and adverse outcomes. A score of 0 suggests low risk, potentially allowing outpatient management, though careful clinical judgement is always required.

• Glasgow-Blatchford Score (GBS): Assesses urea, haemoglobin, systolic blood pressure, pulse, presence of melaena, syncope, hepatic disease, and cardiac failure. A GBS of 0 has a very low risk of needing intervention.

• Rockall Score: Both pre-endoscopy and post-endoscopy versions exist. The post-endoscopy score is more predictive of re-bleeding and mortality once endoscopic findings are known. While useful, the GBS is generally preferred for initial management decisions.

3. Pharmacological Management

Proton Pump Inhibitors (PPIs)

• Non-variceal bleed: Intravenous PPI therapy (e.g., omeprazole 80mg bolus, then 8mg/hour infusion) should be initiated prior to endoscopy in patients suspected of having a non-variceal UGI bleed. This helps stabilise the clot and reduce re-bleeding rates, though it does not improve mortality or reduce the need for intervention. Oral PPIs can be used for patients with GBS=0 if outpatient management is considered.

Reversal of Anticoagulation/Antiplatelets

• Assess the patient's antithrombotic medications. Discuss with haematology or senior colleagues.

• Warfarin: Rapid reversal with Vitamin K and prothrombin complex concentrate (PCC) if INR is high and there's active bleeding.

• DOACs: Specific reversal agents are available (e.g., idarucizumab for dabigatran, andexanet alfa for rivaroxaban/apixaban) or PCC/activated prothrombin complex concentrate (aPCC) depending on the agent.

• Antiplatelets (aspirin, clopidogrel): Platelet transfusions are generally not recommended unless the patient is already thrombocytopenic or has a qualitative platelet defect, and is undergoing surgery, or has a severe, refractory bleed on antiplatelets.

Vasoconstrictors for Variceal Bleeds

• Terlipressin: Should be given early in suspected variceal bleeding (e.g., patients with known liver disease, stigmata of chronic liver disease, or portal hypertension) to reduce portal pressure. Dosage is typically 2mg IV every 4 hours initially, then reduced.

• Octreotide: Less evidence than terlipressin, often used as an alternative or adjunct in some centres.

4. Endoscopic Management

Endoscopy is the cornerstone of diagnosis and definitive treatment for most UGI bleeds.

• Timing:

  • Emergency (within 6-12 hours): For most patients with significant UGI bleeding.

  • Urgent (within 24 hours): For haemodynamically stable patients or those with a low GBS.

• Therapeutic Options: Endoscopists will employ various techniques based on findings:

  • Peptic Ulcer Bleed: Endoscopic haemostasis (e.g., adrenaline injection with clipping or thermal coagulation) is highly effective for high-risk stigmata (active bleeding, visible vessel, adherent clot).

  • Variceal Bleed: Oesophageal variceal band ligation (OVBL) or sclerotherapy are the treatments of choice. Balloon tamponade (Sengstaken-Blakemore tube) is a temporising measure for massive uncontrolled variceal bleeding, bridge to definitive treatment or TIPS.

  • Mallory-Weiss Tear: Usually self-limiting, but endoscopic therapy (clipping, adrenaline) can be used if active bleeding persists.

5. Post-Endoscopy Management and Follow-up

• Continued PPIs: For non-variceal bleeds, high-dose oral PPIs are continued for several weeks (e.g., omeprazole 20-40mg daily) to prevent re-bleeding and promote healing, especially in patients with high-risk stigmata treated endoscopically.

• H. pylori Eradication: If a peptic ulcer is found and H. pylori is positive, eradication therapy is essential to prevent recurrence.

• Secondary Prophylaxis for Varices: Non-selective beta-blockers (e.g., propranolol or carvedilol) and/or repeated endoscopic band ligation are crucial for preventing re-bleeding from varices.

• Surgery/Interventional Radiology: Consider if endoscopic management fails (e.g., refractory bleeding, massive re-bleed). This includes transjugular intrahepatic portosystemic shunt (TIPS) for refractory variceal bleeds or surgical repair for intractable non-variceal bleeding.

Key Takeaways for the SCE

1. Prioritise Resuscitation: Always ABCDE, aim for haemodynamic stability before anything else.

2. Risk Stratify: Understand and apply the Glasgow-Blatchford Score for initial decision-making.

3. Early PPIs for Non-Variceal: IV PPIs before endoscopy in suspected non-variceal bleeds.

4. Terlipressin for Variceal: Initiate early if variceal bleed is suspected.

5. Timing of Endoscopy: Most significant bleeds need endoscopy within 12-24 hours. Know when emergency endoscopy (within 6 hours) is indicated.

6. Understand Endoscopic Therapies: Be familiar with the different methods for variceal and non-variceal bleeds.

7. Long-term Prevention: Know the roles of H. pylori eradication, long-term PPIs, and secondary prophylaxis for varices.

Mastering these guidelines will not only help you ace your SCE in Gastroenterology but, more importantly, equip you to manage one of the most critical emergencies in internal medicine with confidence and competence. Good luck with your preparation!