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Internal MedicineGastroenterologyUpper Gastrointestinal Bleeding

Upper Gastrointestinal Bleeding (UGIB)

Introduction

Upper Gastrointestinal Bleeding (UGIB) is a common medical emergency encountered by Canadian physicians. For MCCQE1 preparation, mastering the approach to UGIB is essential, as it tests multiple CanMEDS roles, particularly Medical Expert (acute resuscitation, diagnosis) and Collaborator (consultation with Gastroenterology and Surgery).

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Definition: UGIB is defined as bleeding derived from a source proximal to the Ligament of Treitz (duodenojejunal flexure).

In Canada, the incidence of UGIB is approximately 100 to 170 cases per 100,000 adults per year. Despite advances in therapy, mortality rates remain between 5% and 10%, largely due to the increasing age and comorbidities of the patient population.

Etiology

Understanding the etiology is crucial for the differential diagnosis on the MCCQE1. Causes are broadly categorized into Non-Variceal and Variceal bleeding.

Common Causes of UGIB

CategoryEtiologyKey Features for MCCQE1
Peptic Ulcer Disease (PUD)H. pylori, NSAIDsMost common cause (~50%). Epigastric pain, history of NSAID use.
Gastroduodenal ErosionsAlcohol, NSAIDs, Stress”Coffee-ground” emesis, often less severe than PUD.
Esophagogastric VaricesPortal Hypertension (Cirrhosis)Life-threatening. Stigmata of liver disease (ascites, jaundice, spider angiomata).
Mallory-Weiss TearSevere vomiting/retchingLongitudinal mucosal tear at GE junction. Alcohol use disorder is a risk factor.
MalignancyGastric/Esophageal CaWeight loss, early satiety, dysphagia, older age.
Dieulafoy’s LesionVascular malformationLarge, tortuous arteriole in stomach wall. Massive, painless bleeding.

Clinical Presentation

The clinical presentation helps localize the bleed and estimate severity.

  • Hematemesis: Vomiting of bright red blood or “coffee-ground” material. Suggests proximal source.
  • Melena: Black, tarry, foul-smelling stool. Indicates blood has been in the GI tract for at least 14 hours. Requires as little as 50-100 mL of blood.
  • Hematochezia: Bright red blood per rectum. Usually lower GI bleed, but can occur in massive UGIB (brisk transit) associated with hemodynamic instability.

Hemodynamic Instability

Assessment of volume status is the priority.

⚠️ Clinical Signs of Shock

  • Resting Tachycardia (HR > 100 bpm)
  • Hypotension (Systolic BP < 90 mmHg)
  • Orthostatic changes (Drop in SBP > 20 mmHg or rise in HR > 20 bpm)
  • Cool, clammy extremities
  • Altered mental status

Initial Management and Resuscitation

The immediate management of UGIB follows the ABCs. Do not rush to endoscopy before stabilizing the patient. This is a frequent trap in MCCQE1 questions.

Step 1: Airway and Breathing

Assess airway patency. Consider elective intubation for airway protection in patients with:

  • Massive hematemesis (risk of aspiration).
  • Altered mental status (GCS < 8).
  • Agitation requiring sedation for endoscopy.

Step 2: Circulation and Access

  • Establish two large-bore IVs (18G or larger).
  • Initiate fluid resuscitation with crystalloids (Ringers Lactate or Normal Saline).
  • Send blood work: CBC, Electrolytes, BUN, Creatinine, INR/PTT, LFTs, and Type & Crossmatch.

Step 3: Transfusion Protocol

Adopt a restrictive transfusion strategy (based on Canadian Guidelines/Choosing Wisely Canada).

  • Transfuse RBCs if Hemoglobin < 70 g/L (Target 70-90 g/L).
  • Exception: In patients with active massive bleeding or acute coronary syndrome, target may be higher.
  • Correct coagulopathy (FFP/Platelets) if INR > 1.5 or Platelets < 50,000/µL.

Step 4: Medical Therapy (Pre-Endoscopy)

  • IV Proton Pump Inhibitor (PPI): Pantoprazole 80 mg IV bolus followed by 8 mg/hr infusion (or high-dose intermittent).
  • Prokinetics: Erythromycin 250 mg IV (30-90 mins pre-endoscopy) to clear the stomach and improve visualization.
  • Vasoactive Agents (if varices suspected): Octreotide 50 mcg IV bolus + 50 mcg/hr infusion.
  • Antibiotics (if cirrhosis present): Ceftriaxone 1g IV daily (prophylaxis against SBP).

Diagnostic Investigation & Risk Stratification

Laboratory Findings

A key pearl for distinguishing UGIB from Lower GI Bleed involves the BUN/Creatinine ratio.

// Medical Formula Concept
if (BUN / Creatinine_Ratio > 30) {
  Probability_of_UGIB = "High";
}
// Note: This is due to absorption of blood proteins in the small bowel.

Risk Stratification Scores

Use these scores to determine disposition (ICU vs. Ward vs. Discharge).

  1. Glasgow-Blatchford Score (GBS): Uses only clinical and lab data (no endoscopy required). Useful for identifying low-risk patients who can be discharged.
  2. Rockall Score: Includes endoscopic findings. Predicts re-bleeding and mortality.

Management Strategies

Management differs significantly based on the etiology.

Peptic Ulcer Disease & Others

  1. Endoscopy (EGD): Should be performed within 24 hours of presentation.
  2. Endoscopic Therapy:
    • Required for high-risk stigmata: Active bleeding, visible vessel, or adherent clot.
    • Modalities: Epinephrine injection (never monotherapy) + Thermal therapy (coagulation) or Mechanical therapy (clips).
  3. Post-Endoscopy Care:
    • High-dose PPI: Continue for 72 hours post-endoscopy for high-risk lesions.
    • H. pylori testing: Biopsy during endoscopy. Treat if positive (“Test and Treat”).
    • NSAID management: Stop NSAIDs. If aspirin is for secondary cardiac prevention, restart within 1-3 days once hemostasis is achieved.

Canadian Guidelines

The Canadian Association of Gastroenterology (CAG) Consensus Group on Non-Variceal Upper Gastrointestinal Bleeding provides key recommendations relevant to the MCCQE1.

  • Timing of Endoscopy: Within 24 hours for most patients. Urgent endoscopy (<12 hours) for patients with hemodynamic instability despite resuscitation.
  • PPI Therapy: High-dose PPI therapy is recommended for patients with endoscopic high-risk stigmata.
  • Transfusion: Restrictive strategy (Threshold < 70 g/L) is associated with lower mortality and re-bleeding rates compared to liberal strategies, except in patients with exsanguinating hemorrhage or acute myocardial ischemia.

Key Points to Remember for MCCQE1

  • Resuscitation first: Always stabilize hemodynamics before sending for endoscopy.
  • Nasogastric (NG) Lavage: Routine use is not recommended for diagnosis or prognosis in Canada.
  • Cirrhotic Patients: Any GIB in a cirrhotic is variceal until proven otherwise. Start Octreotide and Antibiotics immediately.
  • Aorto-enteric Fistula: Consider in any patient with a “herald bleed” and a history of abdominal aortic aneurysm (AAA) repair.
  • Discharge Planning: Patients with a Glasgow-Blatchford Score of 0-1 may be safely managed as outpatients.

Study Checklist

  • Memorize the hemodynamic signs of shock.
  • Review the distinguishing features of Melena vs. Hematochezia.
  • Understand the mechanism and indication for Octreotide.
  • Know the difference between Restrictive vs. Liberal transfusion thresholds.
  • Review the H. pylori eradication regimens common in Canada (Quadruple therapy).

Sample Question

Clinical Scenario

A 52-year-old male presents to the Emergency Department with a 2-hour history of vomiting bright red blood. He has a history of alcohol use disorder and osteoarthritis. On examination, he is diaphoretic and confused. His blood pressure is 80/50 mmHg and heart rate is 115 bpm. Abdominal examination reveals mild distension and shifting dullness. Two large-bore intravenous lines are established.

Question

Which one of the following is the most appropriate immediate next step in management?

  • A. Intravenous pantoprazole 80 mg bolus
  • B. Urgent upper endoscopy
  • C. Infusion of 1 liter of crystalloid fluid
  • D. Insertion of a Sengstaken-Blakemore tube
  • E. Transfusion of 2 units of O-negative packed red blood cells

Explanation

The correct answer is:

  • C. Infusion of 1 liter of crystalloid fluid

Detailed Analysis

  • C is correct: This patient is in hypovolemic shock (Hypotension, Tachycardia, Altered mental status). The priority in the ABCs (Circulation) is immediate volume resuscitation to restore tissue perfusion. Crystalloids are the initial fluid of choice while blood products are being prepared.
  • A is incorrect: While PPIs are part of the management, they do not take precedence over hemodynamic resuscitation. They stabilize the clot after it forms or prevent rebleeding, but they do not treat shock.
  • B is incorrect: Sending an unstable patient to endoscopy is dangerous. The patient must be resuscitated first. Endoscopy is diagnostic and therapeutic but follows stabilization.
  • D is incorrect: Balloon tamponade is a rescue therapy for confirmed variceal bleeding that is uncontrolled by endoscopic means. It is not an initial resuscitation step.
  • E is incorrect: While blood transfusion will likely be needed, immediate crystalloid infusion is faster to initiate while waiting for blood products (even emergency release blood takes minutes). However, if crystalloids fail or bleeding is massive, blood is the next step. In the context of “immediate next step” upon establishing IV access in a shock state, starting fluids is the standard first action in ATLS/ACLS protocols. Note: In a massive transfusion protocol scenario, blood and fluids are often started simultaneously, but option C represents the fundamental first physiologic requirement.

References

  1. Barkun AN, et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med. 2019.
  2. Toronto Notes 2024. Gastroenterology Chapter: Upper GI Bleeding.
  3. Tripathi D, et al. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015.
  4. Medical Council of Canada. MCCQE Part I Objectives: Gastrointestinal Bleeding.
  5. Choosing Wisely Canada. Transfusion Medicine: Red Blood Cells. Link 
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Lower Gastrointestinal BleedingVomiting And Or Nausea