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Gastrointestinal & Hepatic System

Upper Gastrointestinal Bleeding (UGIB)

Bleeding originating from a source proximal to the ligament of Treitz (oesophagus, stomach, duodenum). Can range from minor to life-threatening haemorrhage.

Also known as: UGIB, Vomiting Blood, Bleeding Ulcer, Variceal Bleeding

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Referral and warning signs

When to refer

Urgent hospital admission (H/RR) required for ALL cases of significant UGIB for resuscitation, risk stratification (e.g., Glasgow-Blatchford score), urgent endoscopy, and potential therapeutic intervention. Transfer to facility with endoscopy and blood bank capabilities.

Red flags

  • Haemodynamic instability (hypotension, tachycardia, syncope)
  • Large volume haematemesis or haematochezia
  • Stigmata of high-risk bleeding on endoscopy (active arterial spurt, visible vessel, adherent clot)
  • Signs of chronic liver disease (jaundice, ascites, encephalopathy - suspect varices)
  • Failure to respond to initial resuscitation
  • Coagulopathy

Signs and symptoms

  • Haematemesis (vomiting fresh red blood or 'coffee grounds' - altered blood).
  • Melaena (black, tarry, foul-smelling stools) - indicates blood has been present in upper GI tract long enough to be digested.
  • Haematochezia (passage of fresh red blood per rectum) - can occur with massive, rapid UGIB.
  • Symptoms of blood loss/hypovolemia: Dizziness, lightheadedness, syncope, weakness, pallor, sweating, tachycardia, hypotension.
  • Symptoms related to underlying cause: Epigastric pain (PUD), dysphagia (oesophagitis/cancer), retching (Mallory-Weiss), jaundice/stigmata of chronic liver disease (varices).

Risk factors

  • Peptic Ulcer Disease (PUD) - H. pylori infection, NSAID use
  • Gastro-oesophageal Varices - Portal hypertension (cirrhosis, schistosomiasis)
  • Gastritis / Duodenitis (erosive)
  • Oesophagitis
  • Mallory-Weiss Tear (mucosal tear at gastro-oesophageal junction due to forceful vomiting/retching)
  • Gastric/Oesophageal Cancer
  • Arteriovenous malformations (AVMs)
  • Dieulafoy's lesion
  • Aorto-enteric fistula (rare, post-aortic surgery)

Diagnosis

Clinical assessment

Diagnosis based on history (haematemesis, melaena) and signs of blood loss/hypovolemia. Assess severity (vital signs, postural changes). Identify potential cause based on history/stigmata (NSAIDs, alcohol, liver disease). Differentiate from haemoptysis (coughing blood from lungs).

Investigations

  • Nasogastric (NG) Tube Aspiration/Lavage: Can confirm recent/ongoing upper GI source (blood/coffee grounds), help clear stomach for endoscopy. Absence of blood does not rule out UGIB (esp. duodenal source).
  • Upper GI Endoscopy (OGD - Oesophagogastroduodenoscopy): Gold standard. Identifies bleeding source, allows risk stratification (e.g., Forrest classification for ulcers), and enables therapeutic intervention (injection, clipping, thermal coagulation, banding of varices). Should be performed urgently (within 24h, sooner if unstable/high risk).
  • Blood tests: Complete Blood Count (CBC - Hb/Hct may be normal initially, check platelets), Blood Group & Cross-match (URGENT), Urea & Electrolytes (BUN/Creatinine ratio often elevated), Coagulation screen (INR/PTT), Liver Function Tests (LFTs - assess for liver disease).

Diagnostic criteria

Clinical presentation confirmed by endoscopic visualization of bleeding source, or strong clinical evidence (haematemesis/melaena) with response to specific treatment (e.g., variceal banding).

Management

Non-pharmacological management

  • Resuscitation (Priority):
  • - ABCs: Airway protection (intubation if altered mental status, massive haematemesis).
  • - Circulation: Establish large-bore IV access (x2). Aggressive fluid resuscitation (crystalloids) for hypovolemia.
  • - Blood Transfusion: Transfuse packed red blood cells (PRBCs) based on clinical assessment and Hb targets (typically aim Hb >7-8 g/dL, higher target in specific situations). Correct coagulopathy (FFP, platelets if needed).
  • NG tube placement (optional, see investigations).
  • Keep NPO initially.
  • Endoscopic Therapy: Injection (adrenaline), thermal coagulation, mechanical clips for PUD bleeding. Band ligation or sclerotherapy for oesophageal varices.

Pharmacological treatment

  • Acid Suppression (Non-variceal bleeding, esp. PUD):
  • - Proton Pump Inhibitors (PPIs): High-dose IV PPI (e.g., Omeprazole/Pantoprazole 80mg bolus then 8mg/hr infusion for 72h) recommended post-endoscopic therapy for high-risk ulcers to reduce rebleeding. Oral PPI (e.g., Omeprazole 20-40mg OD/BID) for lower-risk ulcers/prophylaxis.
  • Variceal Bleeding (Requires specific management):
  • - Vasoactive Drugs: Start immediately if varices suspected. Terlipressin IV OR Octreotide IV infusion (or Somatostatin). Reduces portal pressure.
  • - Antibiotic Prophylaxis: Broad-spectrum antibiotic (e.g., Ceftriaxone 1g IV daily for 5-7 days) significantly reduces mortality and rebleeding in cirrhotic patients with variceal bleed (prevents SBP/other infections).
  • Discontinue NSAIDs/Aspirin if possible.
  • Helicobacter pylori eradication therapy if PUD is H. pylori positive (after acute bleed controlled).

Monitoring

  • Continuous vital signs (HR, BP, SpO2).
  • Monitor for signs of ongoing bleeding (haematemesis, melaena, haematochezia, vital sign changes).
  • Monitor haemoglobin levels.
  • Monitor urine output.
  • Monitor for complications of endoscopy or transfusion.

Complications

  • Hypovolemic shock
  • Rebleeding
  • Aspiration pneumonia
  • Complications of endoscopy (perforation, bleeding)
  • Complications of transfusion
  • Myocardial infarction/ischaemia (due to hypotension/anaemia)
  • Renal failure
  • Hepatic encephalopathy (in cirrhotic patients)
  • Death

Prevention

  • Eradication of H. pylori for PUD.
  • Avoidance/cautious use of NSAIDs (use PPI co-therapy if high risk).
  • Primary prophylaxis for oesophageal varices (non-selective beta-blockers like Propranolol, or endoscopic band ligation).
  • Management of chronic liver disease/portal hypertension.

Patient education

  • Explain likely cause of bleeding (ulcer, varices etc.).
  • Importance of endoscopy for diagnosis and treatment.
  • Need for medications (PPIs, H. pylori eradication, variceal prophylaxis).
  • Avoidance of NSAIDs, alcohol.
  • Signs of rebleeding to report immediately.
  • Lifestyle changes (diet, smoking).
  • Follow-up plan.

Uganda-specific notes

Variceal bleeding due to cirrhosis (HBV, Schistosomiasis, alcohol) and PUD (H. pylori, NSAIDs) are major causes. Access to urgent endoscopy, blood transfusion, and specific therapies (banding, PPI infusions, vasoactive drugs) is often limited to referral centres. Resuscitation and stabilization are key initial steps.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 6, Section 6.1.3

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