What are the causes, symptoms, physical examination findings, differential diagnosis, and management of upper gastrointestinal bleeding for a National Assessment Centre Objective Structured Clinical Examination?

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Upper GI Bleeding: NAC OSCE Guide

CAUSES

Upper GI bleeding originates from the mouth to the ligament of Treitz 1. The causes fall into two main categories:

Non-Variceal Causes (Most Common)

  • Peptic ulcer disease (30-50% of cases) - most common overall 1
  • Gastritis and esophagitis 1
  • Mallory-Weiss tears (MWT) - mucosal tears from forceful vomiting 2
  • Dieulafoy's lesions - abnormal vessels in the GI wall 2
  • Malignant tumors 2
  • Gastric antral vascular ectasia 2

Variceal Causes

  • Esophageal varices - from portal hypertension/cirrhosis 3
  • Gastric varices 3

Key Risk Factors

  • Prior upper GI bleeding history
  • Anticoagulant use (warfarin, DOACs)
  • High-dose NSAIDs
  • Older age 1

SYMPTOMS

Patients present with bleeding manifestations and signs of volume loss 1:

Bleeding Symptoms

  • Hematemesis - vomiting bright red blood (active bleeding)
  • Coffee-ground emesis - vomiting dark material (older blood)
  • Melena - black, tarry, foul-smelling stools (digested blood)
  • Hematochezia - bright red blood per rectum (massive upper GI bleed with rapid transit) 4

Volume Loss Symptoms

  • Lightheadedness and dizziness
  • Syncope
  • Abdominal pain 1

PHYSICAL EXAMINATION

Your exam must assess hemodynamic stability first, then look for bleeding source clues 1:

Vital Signs (Critical First Step)

  • Tachycardia - heart rate >100 bpm
  • Hypotension - systolic BP <90 mmHg
  • Orthostatic changes - drop in BP or rise in HR when standing
  • Shock signs - cold extremities, altered mental status 4

Abdominal Examination

  • Tenderness or rebound tenderness (suggests perforation)
  • Epigastric pain (peptic ulcer)
  • Hepatomegaly or ascites (cirrhosis/varices) 1

Other Key Findings

  • Stigmata of chronic liver disease: spider angiomas, palmar erythema, jaundice, caput medusae (suggests variceal bleeding) 3
  • Digital rectal exam: assess stool color - melena vs hematochezia 1
  • Pallor (anemia)

DIAGNOSIS

Initial Laboratory Tests

Order these immediately 1:

  • Complete blood count - hemoglobin may be normal initially despite significant blood loss
  • Basic metabolic panel - assess renal function
  • Coagulation panel (PT/INR, aPTT) - especially if on anticoagulants
  • Liver function tests - evaluate for cirrhosis
  • Type and crossmatch - prepare for transfusion

Risk Stratification Scores

Use Glasgow-Blatchford Score (GBS) to identify very low-risk patients 5:

  • GBS ≤1: Patient at very low risk for rebleeding/mortality
  • These patients may NOT require hospitalization or urgent endoscopy 5
  • Can be managed as outpatients 6

Do NOT use AIMS65 score for risk stratification - insufficient evidence 5

Nasogastric Tube

  • Consider placement in selected patients for prognostic value 5
  • Can help differentiate upper vs lower GI source

Endoscopy Timing

Perform endoscopy within 24 hours of presentation for hospitalized patients 5, 3. This is the diagnostic gold standard and allows therapeutic intervention 4.

For patients with hemodynamic instability or suspected variceal bleeding, consider urgent endoscopy after initial resuscitation 1.

MANAGEMENT

Step 1: Immediate Resuscitation

Start resuscitation BEFORE endoscopy for hemodynamically unstable patients 5:

Fluid Resuscitation

  • Rapid infusion of normal saline or lactated Ringer's to correct hypovolemia and maintain blood pressure 1

Blood Transfusion Strategy

  • Restrictive transfusion threshold: Hemoglobin <7-8 g/dL for most patients 1, 3, 6
  • Higher threshold for patients with cardiovascular disease 5
  • This restrictive approach improves outcomes 3

Step 2: Pre-Endoscopic Pharmacotherapy

For Suspected Non-Variceal Bleeding

Start intravenous proton pump inhibitors (PPIs) immediately upon presentation 1, 4:

  • Decreases probability of high-risk stigmata at endoscopy 4
  • May downstage endoscopic lesion 5
  • Should NOT delay endoscopy 5

Consider erythromycin (prokinetic agent) 30-60 minutes before endoscopy 4, 7:

  • Improves visualization by clearing stomach contents 7

For Suspected Variceal Bleeding

If cirrhosis or portal hypertension suspected, give BEFORE endoscopy 3, 6:

  • Antibiotics (e.g., ceftriaxone) - reduces mortality 3, 6
  • Vasoactive drugs (octreotide, terlipressin) - controls bleeding 3, 6

Step 3: Anticoagulation Management

Do NOT delay endoscopy in patients on anticoagulants (warfarin, DOACs) 5. Endoscopy with or without hemostatic therapy can proceed safely.

Step 4: Endoscopic Treatment

Non-Variceal Bleeding

Endoscopic therapy is indicated ONLY for high-risk stigmata 5:

  • Active bleeding (spurting or oozing)
  • Non-bleeding visible vessel
  • Adherent clot

Do NOT treat low-risk stigmata 5:

  • Clean-based ulcer
  • Flat pigmented spot

Endoscopic techniques (use alone or in combination) 4:

  • Injection therapy: Epinephrine injection - MUST be combined with another method, never use alone 4
  • Thermal therapy: Contact thermocoagulation, argon plasma coagulation
  • Mechanical therapy: Through-the-scope clips, endoscopic band ligation

Specific lesion management 2:

  • Mallory-Weiss tears with active bleeding: Band ligation or clips over epinephrine alone
  • Mallory-Weiss tears without active bleeding: Do NOT treat 2
  • Dieulafoy's lesions: Mechanical methods (clips/band ligation), contact thermocoagulation, or sclerosants over epinephrine alone 2
  • Malignant tumors: Topical hemostatic agents over conventional therapy 2
  • Gastric antral vascular ectasia: Band ligation over argon plasma coagulation 2

Variceal Bleeding

  • Esophageal varices: Endoscopic band ligation 3
  • Gastric varices: Thrombin or tissue glue injection 3

Step 5: Post-Endoscopic Care

For Non-Variceal Bleeding Requiring Endoscopic Therapy

Give high-dose PPI for 72 hours post-endoscopy 1, 6:

  • This is when rebleeding risk is highest 1
  • Then transition to standard PPI dosing

For Variceal Bleeding

Continue antibiotics and vasoactive drugs after endoscopy 6

Early Discharge Criteria

Selected low-risk patients can be discharged promptly after endoscopy 5:

  • Low clinical risk scores
  • Low-risk endoscopic findings (clean-based ulcer, flat pigmented spot)

Step 6: Management of Rebleeding

Non-Variceal Rebleeding

  1. First-line: Repeat endoscopic therapy 3, 7
  2. Second-line: Transcatheter arterial embolization (TAE) - preferred over surgery 3, 7
  3. Third-line: Surgery - if TAE fails 3

Variceal Rebleeding

  1. First-line: Repeat endoscopic treatment 3
  2. Second-line: Transjugular intrahepatic portosystemic shunt (TIPS) 3, 6

COMMON PITFALLS

  • Don't wait for hemoglobin to drop before transfusing - initial hemoglobin may be falsely normal due to hemoconcentration 1
  • Never use epinephrine injection alone - always combine with mechanical or thermal therapy 4
  • Don't treat Mallory-Weiss tears without active bleeding - they heal spontaneously 2
  • Don't delay antibiotics/vasopressors if variceal bleeding suspected - give before endoscopy 3
  • Don't delay endoscopy in anticoagulated patients - proceed safely with or without reversal 5
  • Don't use liberal transfusion strategy - restrictive approach (Hgb <7-8 g/dL) improves outcomes 3, 6

References

4
Research

Non-variceal Upper Gastrointestinal Bleeding and Its Endoscopic Management.

The Turkish journal of gastroenterology : the official journal of Turkish Society of Gastroenterology, 2024

6
Research

Management of acute upper gastrointestinal bleeding.

BMJ (Clinical research ed.), 2019

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.