Diagnosis

• Blatchford score before assessment, if 0 then early discharge
• Rockall score after assessment

Investigation

• n/a

Management

• Stop NSAIDS during acute phase
• Maintain low dose aspirin once haemostasis achieved
• Consider risk benefit of Clopidogrel with specialist input
• Acid suppression therapy (H2 receptor antagonist or PPI) for acutely ill patients in critical care

Massive bleed

• Transfuse with blood, platelets and clotting factors per local protocol, base on full clinical picture
• Platelet transfusion for patients actively bleeding and platelet count < 50 x 109 /l
• FFP fibrinogen < 1 g/l or INR or APTT > 1.5 x normal
• Pro-thrombin complex for those actively bleeding and on Warfarin
• Endoscopy for all unstable patients after resus, and all patients with upper GI bleed within 24 hrs

Non-variceal bleeding

• Endoscopic therapy, repeat procedure if doubt over haemostasis:
• Mechanical clips with or without adrenaline
• Thermal coagulation with adrenaline
• Fibrin or thrombin with adrenaline
• Offer interventional radiology who re-bleed after endoscopy, or emergency surgery
• PPI: only offer post endoscopy following evidence of recent haemorrhage

Variceal bleed

• Terlipressin at presentation until definitive haemostasis, consider prophylactic antibiotics
• Endoscopic band ligation should be offered

Gastric varices

• Endoscopic injection of N-butyl-2-cyanoacrylate Or TIPS (Transjugular Intrahepatic Portosystemic Shunt) not successful

NICE Source: CG141 Acute upper gastrointestinal bleeding in over 16s: management. Summary compiled by Dr D P Sheppard MBBS.