Emergency · Free article
Acute upper GI bleeding: Blatchford, Rockall, Forrest and what to do when endoscopy fails
Acute upper GI bleeding for FRCS (Gen Surg): Glasgow-Blatchford and Rockall scores, Forrest stigmata, NICE CG141, variceal care, embolisation and ulcer surgery.
Causes
Peptic ulcer is the commonest cause of acute upper gastrointestinal bleeding, followed by oesophagitis and gastritis, varices, Mallory–Weiss tears and malignancy. Rarer causes are a Dieulafoy lesion, angiodysplasia, an aortoenteric fistula after aortic surgery, haemobilia and haemosuccus pancreaticus. The history should cover previous bleeds, liver disease and alcohol, aortic grafts, and drugs: NSAIDs, aspirin and other antiplatelets, anticoagulants and SSRIs.
Risk assessment
The Glasgow-Blatchford score uses information available at the front door and predicts the need for intervention (transfusion, endoscopic therapy or surgery). It is the score that decides who can go home. NICE CG141 suggests considering early discharge, with outpatient endoscopy, when the pre-endoscopy score is 0; the European (ESGE) guideline accepts a score of 0 or 1.
| Admission marker | Points |
|---|---|
| Blood urea 6.5–7.9 / 8.0–9.9 / 10.0–24.9 / 25 mmol/L or more | 2 / 3 / 4 / 6 |
| Haemoglobin in men: 120–129 / 100–119 / below 100 g/L | 1 / 3 / 6 |
| Haemoglobin in women: 100–119 / below 100 g/L | 1 / 6 |
| Systolic blood pressure 100–109 / 90–99 / below 90 mmHg | 1 / 2 / 3 |
| Pulse 100/min or more | 1 |
| Melaena | 1 |
| Syncope | 2 |
| Hepatic disease | 2 |
| Cardiac failure | 2 |
The Rockall score predicts death and rebleeding. The pre-endoscopy (clinical) score uses age, shock and comorbidity; the full score adds the endoscopic diagnosis and stigmata of recent haemorrhage, to a maximum of 11. The AIMS65 score (albumin, INR, altered mental state, systolic pressure, age 65 or over) is an alternative predictor of mortality.
| Component | 0 | 1 | 2 | 3 |
|---|---|---|---|---|
| Age | Under 60 | 60–79 | 80 or over | — |
| Shock | None | Pulse 100 or more, systolic 100 or more | Systolic below 100 | — |
| Comorbidity | None major | — | Cardiac failure, ischaemic heart disease or other major comorbidity | Renal failure, liver failure or disseminated malignancy |
| Diagnosis | Mallory–Weiss tear, or no lesion and no stigmata | All other diagnoses | Upper GI malignancy | — |
| Major stigmata | None, or dark spot only | — | Blood in the upper GI tract, adherent clot, visible or spurting vessel | — |
Resuscitation and the first hours
- Access and bloods. Two large-bore cannulae; full blood count, urea and electrolytes, liver tests, clotting, group and cross-match, and a lactate.
- Transfusion. A restrictive strategy is safer for most patients. Villanueva (NEJM 2013) found better survival with a threshold of 70 g/L than with 90 g/L; a higher threshold is used in patients with cardiovascular disease. NICE reminds us that over-transfusion may be as damaging as under-transfusion.
- Blood products. Platelets for active bleeding with a count below 50 × 10⁹/L; fresh frozen plasma for active bleeding with a prothrombin time or APTT more than 1.5 times normal; cryoprecipitate if fibrinogen stays below 1.5 g/L; prothrombin complex concentrate for patients on warfarin who are actively bleeding. Reverse other anticoagulants by local protocol.
- Tranexamic acid. HALT-IT (Lancet 2020) found no reduction in death from gastrointestinal bleeding and more venous thromboembolic events. It is not used routinely.
- Acid suppression. NICE advises against PPIs or H2-receptor antagonists before endoscopy in suspected non-variceal bleeding.
- Suspected varices. Terlipressin and prophylactic antibiotics at presentation. Stop terlipressin after definitive haemostasis, or after 5 days unless there is another reason to continue.
Endoscopy
NICE CG141 asks for endoscopy immediately after resuscitation in unstable patients with severe bleeding, and within 24 hours of admission for everyone else. Earlier is not always better: in a randomised trial of high-risk patients (Lau, NEJM 2020), endoscopy within 6 hours did not reduce 30-day mortality compared with endoscopy at 6–24 hours.
| Forrest | Appearance | Endoscopic therapy |
|---|---|---|
| Ia | Spurting arterial bleeding | Yes |
| Ib | Oozing | Yes |
| IIa | Non-bleeding visible vessel | Yes |
| IIb | Adherent clot | Consider removing the clot and treating what lies beneath |
| IIc | Flat pigmented spot | No |
| III | Clean base | No |
- Methods (NICE). A mechanical method such as clips, with or without adrenaline; thermal coagulation with adrenaline; or fibrin or thrombin with adrenaline. Adrenaline alone is not enough. Haemostatic powders are a temporary or rescue option.
- After haemostasis. A PPI for patients with stigmata of recent haemorrhage, a test for Helicobacter pylori with eradication if positive, and stopping NSAIDs. Continue low-dose aspirin for secondary prevention once haemostasis is achieved, and discuss clopidogrel and other antiplatelets with the relevant specialist.
- Second look. Consider repeat endoscopy for patients at high risk of rebleeding, particularly if haemostasis at the first endoscopy was in doubt.
Rebleeding: radiology or surgery
A patient who rebleeds is offered repeat endoscopy, with a view to further endoscopic treatment or emergency surgery. NICE recommends interventional radiology for unstable patients who rebleed after endoscopic treatment, and urgent referral for surgery if radiology is not promptly available. Transcatheter arterial embolisation targets the gastroduodenal artery for duodenal ulcers or the left gastric artery for lesser curve gastric ulcers, and can be done empirically when no extravasation is seen.
Operating on a bleeding ulcer
- Posterior duodenal ulcer. The bleeding vessel is the gastroduodenal artery. Through a longitudinal duodenotomy, or a pyloroduodenotomy, the ulcer is under-run with non-absorbable sutures placed above and below the bleeding point, with a U-stitch for the transverse pancreatic branch. The common bile duct lies close by and must be avoided. A pyloroduodenotomy is closed transversely as a Heineke–Mikulicz pyloroplasty.
- Gastric ulcer. Excise the ulcer, or at least biopsy and under-run it, because of the risk of malignancy. A large lesser curve ulcer eroding the left gastric artery may need a partial gastrectomy.
- After surgery. PPIs and H. pylori eradication have made vagotomy and other acid-reducing operations rarely necessary.
Variceal bleeding
- Oesophageal varices. Band ligation (NICE). Consider a transjugular intrahepatic portosystemic shunt (TIPS) if bleeding is not controlled.
- Gastric varices. Endoscopic injection of N-butyl-2-cyanoacrylate; TIPS if bleeding is not controlled.
- Bridge to definitive treatment. Balloon tamponade with a Sengstaken–Blakemore tube, or a self-expanding oesophageal stent, for uncontrolled bleeding.
- Pre-emptive TIPS. The Baveno VII consensus advises pre-emptive TIPS within 72 hours for selected cirrhotic patients at high risk of treatment failure, such as those with Child–Pugh class C disease.
Rarer causes worth knowing
- Dieulafoy lesion
- A large-calibre submucosal artery that bleeds through a tiny mucosal defect, usually in the upper stomach. Bleeding is intermittent and the lesion is easily missed; clips or band ligation, with a tattoo to mark it.
- Aortoenteric fistula
- Suspect it in anyone with an aortic graft, typically fistulating into the third or fourth part of the duodenum. A small herald bleed may precede massive haemorrhage; CT angiography is the investigation.
- Haemobilia
- Bleeding into the biliary tree after liver trauma, biopsy or biliary intervention. Quincke’s triad is right upper quadrant pain, jaundice and gastrointestinal bleeding; angiographic embolisation is the usual treatment.
- Haemosuccus pancreaticus
- Bleeding through the pancreatic duct, usually from a splenic artery pseudoaneurysm after pancreatitis; treated by embolisation.
- Mallory–Weiss tear
- A mucosal tear at the gastro-oesophageal junction after retching. Most stop spontaneously.
Frequently asked questions
Which patients with upper GI bleeding can be discharged for outpatient endoscopy?
NICE suggests considering early discharge when the pre-endoscopy Glasgow-Blatchford score is 0. The European (ESGE) guideline accepts a score of 0 or 1.
Should a PPI be started before endoscopy?
NICE advises against acid suppression before endoscopy in suspected non-variceal bleeding. A PPI is given after endoscopy to patients with stigmata of recent haemorrhage.
Is tranexamic acid used in gastrointestinal bleeding?
Not routinely. The HALT-IT trial found that tranexamic acid did not reduce death from gastrointestinal bleeding and increased venous thromboembolic events.
What happens if bleeding recurs after endoscopic treatment?
Repeat endoscopy is offered. Unstable patients who rebleed after endoscopic treatment are offered interventional radiology, with urgent surgery if radiology is not promptly available.
Which artery bleeds from a posterior duodenal ulcer, and how is it controlled at surgery?
The gastroduodenal artery. It is under-run through a duodenotomy with sutures above and below the bleeding point and a U-stitch for the transverse pancreatic branch, taking care to avoid the common bile duct.
References
- National Institute for Health and Care Excellence. Acute upper gastrointestinal bleeding in over 16s: management (CG141). 2012, updated 2016.
- Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000;356(9238):1318–1321.
- Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996;38(3):316–321.
- Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. Lancet 1974;2(7877):394–397.
- Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013;368(1):11–21.
- HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet 2020;395(10241):1927–1936.
- Lau JYW, Yu Y, Tang RSY, et al. Timing of endoscopy for acute upper gastrointestinal bleeding. N Engl J Med 2020;382(14):1299–1308.
- Gralnek IM, Stanley AJ, Morris AJ, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021. Endoscopy 2021;53(3):300–332.
- de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VII – Renewing consensus in portal hypertension. J Hepatol 2022;76(4):959–974.
Further reading
- NICE CG141: Acute upper gastrointestinal bleeding in over 16s — Risk scoring, timing of endoscopy, blood products, variceal care and escalation after rebleeding
Written for revision in the FRCS (Gen Surg) style under our editorial standards. It is not clinical advice: always confirm against current guidance. Spotted an error? Tell us.
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