Upper gastrointestinal bleed — haematemesis and melaena

PLAB 2 & PRES 3 · gastro · hard · 8 minutes

Candidate brief

You are an FY2 doctor/SHO in the Emergency Department. Mr Robert Hughes, 68, presents after vomiting blood and passing black stools. He is pale, dizzy and hypotensive. Assess him urgently, explain the likely problem and initiate an appropriate resuscitation, investigation and escalation plan. Verbalise any examinations, prescriptions and referrals you would undertake.

What examiners look for

Haematemesis is vomiting fresh or altered blood. Coffee-ground material indicates that blood has been exposed to stomach acid. Melaena is black, tarry stool caused by digested blood and commonly indicates an upper gastrointestinal source. Assess ABCDE immediately. Tachycardia, hypotension, prolonged capillary refill, syncope, confusion and cool peripheries suggest significant blood loss and shock. Do not wait for the haemoglobin result before treating an unstable patient. Haemoglobin may initially underestimate the severity of acute blood loss. Obtain 2 large-bore IV cannulas and send FBC, renal and liver profiles, coagulation, venous gas and lactate, and group-and-save or crossmatch. Keep the patient nil by mouth, monitor continuously, record fluid balance and reassess after every intervention. Use the Glasgow-Blatchford score before endoscopy. This patient is high risk and is not suitable for discharge. Unstable severe bleeding requires endoscopy immediately after adequate resuscitation. Other admitted patients should receive endoscopy within 24 hours. In UK NICE practice, do not routinely give a PPI before endoscopy for suspected non-variceal bleeding. Give PPI when endoscopy demonstrates recent-haemorrhage stigmata. Stop NSAIDs during the acute bleeding episode. Review the indication and safer long-term analgesia later. Suspected variceal bleeding requires immediate vasoactive treatment and prophylactic antibiotics under the local protocol. Early involvement of gastroenterology, anaesthetics, critical care, transfusion services and interventional radiology or surgery may be required.

Guideline references

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