Orris

What should I know about ugi bleed as SHO in nhs, give in points

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Finding Sources
Searching PubMed

"Gastrointestinal Hemorrhage"[MeSH Terms] AND "upper"

Searching the Web

NICE NG141 acute upper gastrointestinal bleeding management Glasgow-Blatchford transfusion threshold endoscopy timing

Reading File

Upper GI bleed: what an NHS SHO needs to know

1. Basics

  • An upper GI bleed (UGIB) is bleeding proximal to the ligament of Treitz.
  • The commonest cause is still peptic ulcer disease. Other causes are erosive gastritis, oesophagitis and duodenitis, varices, Mallory-Weiss tear, malignancy, Dieulafoy lesion and angiodysplasia.
  • NSAIDs, aspirin, alcohol and smoking are the main drivers. Varices cause fewer bleeds overall but carry a high mortality and rebleed risk.
  • Many patients with known varices actually bleed from a non-variceal source (Tintinalli's Emergency Medicine).

2. First assessment (ABCDE, treat as an emergency until proven otherwise)

  • Presentation: haematemesis, coffee-ground vomit, melaena, dizziness or syncope. Brisk UGIB can present as fresh PR blood.
  • Resuscitation:
    • Give oxygen only if hypoxic.
    • Insert 2 large-bore cannulae (14-16G).
    • Check NEWS2 and consider a catheter for strict fluid balance if unstable.
    • Make the patient nil by mouth.
  • Bloods:
    • FBC, U&E, LFTs, coagulation (including fibrinogen if bleeding heavily), group and save or crossmatch, VBG with lactate, glucose.
    • ECG and troponin if there is cardiac risk.
  • Pitfalls:
    • Hb can be normal early because it falls after haemodilution.
    • Raised urea with normal creatinine suggests an upper source.
    • Beta-blockers can mask tachycardia.
    • Elderly patients can look deceptively stable.
  • History to get:
    • Anticoagulants and antiplatelets (including the DOAC type and the time of the last dose).
    • NSAIDs, steroids, SSRIs, alcohol, liver disease, previous ulcer or bleed, and IHD or heart failure.
    • Weight loss or dysphagia.
  • Examination: look for stigmata of chronic liver disease, do a PR exam for melaena, and check the abdomen.

3. Risk stratification

  • Use the Glasgow-Blatchford score (GBS) at first assessment. NICE CG141 recommends this for all patients with UGIB.
  • Use the Rockall score after endoscopy.
  • A pre-endoscopy GBS of 0 is the group NICE says to consider for early or outpatient management. Some guidelines use 0-1.
  • Anyone with a higher score, haemodynamic instability, active haematemesis, suspected varices or significant comorbidity needs admission.

4. Fluids and blood

  • Give a cautious crystalloid bolus for shock.
  • Avoid over-resuscitation, especially in cirrhosis and heart failure. It raises portal pressure and can increase rebleeding.
  • If bleeding is massive, activate the Major Haemorrhage Protocol early.
  • Use a restrictive transfusion strategy. Many UK trusts use a trigger of Hb below 70 g/L with a target of 70-90 g/L, and slightly higher for IHD. Check your trust policy. The NICE snippet I retrieved was garbled on the exact threshold, so I couldn't confirm it.
  • NICE guidance on correcting coagulopathy:
    • Platelets if actively bleeding and the count is below 50.
    • FFP if fibrinogen is below 1 g/L or PT or APTT is above 1.5 times normal.
    • PCC for patients on warfarin who are actively bleeding (plus IV vitamin K).
  • DOACs: discuss with haematology.
    • Andexanet alfa is a NICE option for life-threatening or uncontrolled GI bleeding on apixaban or rivaroxaban.
    • Idarucizumab reverses dabigatran.

5. Drugs

  • PPI before endoscopy: NICE says not to offer PPIs or H2 blockers before endoscopy in suspected non-variceal bleeding. Many wards still give them, so follow local practice but know the NICE position.
  • PPI after endoscopy: give it to patients with stigmata of recent haemorrhage. High-dose IV PPI is typical for high-risk lesions, then oral.
  • Medicines to hold: NSAIDs, anticoagulants, antihypertensives while hypotensive, and consider metformin if AKI.
  • Aspirin for secondary prevention: don't stop it indefinitely. Restart once haemostasis is secure, and discuss with your senior or gastroenterology.
  • VTE prophylaxis: use mechanical (TEDs or IPC) while actively bleeding.

6. Suspected variceal bleed (chronic liver disease, alcohol history, stigmata)

Start treatment at presentation. Do not wait for endoscopy.
  • Give terlipressin (check contraindications such as IHD or peripheral vascular disease).
  • Give prophylactic IV antibiotics (per local policy, commonly ceftriaxone).
  • Correct coagulopathy cautiously. INR is a poor guide in cirrhosis.
  • Urgent endoscopy within about 12 hours after resuscitation, with band ligation for oesophageal varices.
  • Gastric varices: endoscopic cyanoacrylate injection.
  • If bleeding is uncontrolled: balloon tamponade (Sengstaken or Linton tube) as a bridge, then TIPS. This needs senior and ITU involvement.
  • Treat alcohol withdrawal (CIWA-based chlordiazepoxide, Pabrinex).
  • Give lactulose or phosphate enema to reduce hepatic encephalopathy risk.
  • Check glucose and watch for AKI.

7. Endoscopy timing (NICE CG141)

  • Unstable patients with severe bleeding: endoscopy immediately after resuscitation.
  • Everyone else: endoscopy within 24 hours of admission.
  • Make the referral early and clearly. Quote the GBS, haemodynamics, anticoagulants, comorbidities and your resuscitation so far.

8. After endoscopy

  • Follow the endoscopy report for the PPI plan, diet and timing of restarting medicines.
  • Test for and eradicate H. pylori if relevant.
  • Stop or avoid NSAIDs.
  • Rebleeding:
    • Repeat endoscopy.
    • If an unstable patient rebleeds after endoscopic treatment, interventional radiology (embolisation).
    • If that fails, surgery.
    • Involve surgeons and IR early.

9. Escalation and safety

  • Call your registrar early if:
    • SBP is below 100 or HR above 100
    • there is ongoing haematemesis
    • lactate is raised
    • you need more than 2 units
    • the patient is cirrhotic, anticoagulated or has multiple comorbidities
  • Involve critical care outreach or ITU early for airway risk (large haematemesis, reduced GCS) or refractory shock.
  • Document a ceiling of care and treatment escalation plan (TEP) early, especially in frail patients.
  • Document fluid balance and obs frequency (at least hourly while unstable).
  • Repeat Hb and FBC after resuscitation and transfusion.

10. Common SHO mistakes

  • Under-cannulating, or only one small cannula.
  • Delaying the group and save or crossmatch.
  • Over-fluiding cirrhotic patients.
  • Missing variceal bleeds because terlipressin and antibiotics weren't started.
  • Forgetting to hold anticoagulants or NSAIDs.
  • Assuming a normal Hb means a minor bleed.
  • Poor handover, with no clear plan on Hb thresholds, repeat bloods and escalation triggers.

Recent evidence check

I searched PubMed for the last 2 years of meta-analyses and systematic reviews. Nothing I found contradicts the points above. The most relevant is a 2024 review of current evidence on UGIB management (PMID 38517201). NICE CG141 appears to have been updated recently. Check the current NICE recommendations and your local trust UGIB pathway for drug doses and thresholds.
I can turn this into a one-page quick reference card or a night-shift checklist if that would help.

Make a one-page PDF quick reference card for UGIB

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Running Command

ls -la /tmp/workspace/

Running Command

mkdir -p /tmp/workspace/ugib-card && cat > /tmp/workspace/ugib-card/make.py << 'EOF' from reportlab.lib.pagesizes import A4 from reportlab.pdfgen import canvas from reportlab.lib import colors from reportlab.platypus import Paragraph, Frame, KeepInFrame from reportlab.lib.styles import ParagraphStyle W, H = A4 M = 24 out = "/tmp/workspace/ugib-card/UGIB_Quick_Reference_Card.pdf" c = canvas.Canvas(out, pagesize=A4) c.setTitle("UGIB Quick Reference Card (NHS SHO)") NAVY = colors.HexColor("#1F3A5F"); RED = colors.HexColor("#B3261E"); LIGHT = colors.HexColor("#EEF2F7") # Header c.setFillColor(NAVY); c.rect(0, H-52, W, 52, fill=1, stroke=0) c.setFillColor(colors.white); c.setFont("Helvetica-Bold", 18) c.drawString(M, H-33, "Upper GI Bleed: SHO Quick Reference") c.setFont("Helvetica", 8.5) c.drawRightString(W-M, H-24, "Based on NICE CG141 + standard UK practice") c.drawRightString(W-M, H-37, "Check local trust policy for doses/thresholds") body = ParagraphStyle("b", fontName="Helvetica", fontSize=7.8, leading=9.6, spaceAfter=1.2, leftIndent=7, bulletIndent=0) def B(items): return "".join(f"<bullet>&bull;</bullet>{i}<br/>" for i in items) sections = { "1. ABCDE and first 15 min": [ "Senior/registrar aware early. NEWS2, <b>2 x 14-16G cannulae</b>, NBM", "Bloods: FBC, U&amp;E (urea up), LFT, clotting + fibrinogen, <b>group &amp; save/crossmatch</b>, VBG + lactate, glucose", "ECG +/- troponin if cardiac risk. Catheter if unstable", "Hx: anticoagulant/antiplatelet (DOAC type, last dose), NSAIDs, steroids, SSRI, alcohol, liver disease, prior ulcer", "Exam: melaena on PR, liver stigmata, abdomen", "<b>Traps:</b> Hb may be normal early; beta-blockers mask tachycardia; elderly look well until they crash", ], "2. Risk score": [ "<b>Glasgow-Blatchford (GBS)</b> at first assessment (urea, Hb, SBP, HR, melaena, syncope, liver disease, heart failure)", "GBS <b>0</b>: consider early/outpatient management (some guidelines use 0-1)", "Anything higher, unstable, active haematemesis, varices suspected, or significant comorbidity: <b>admit</b>", "<b>Rockall</b> after endoscopy", ], "3. Fluids and blood": [ "Cautious crystalloid for shock. <b>Avoid over-filling</b>, esp. cirrhosis and heart failure", "Massive bleed: activate <b>Major Haemorrhage Protocol</b>", "Restrictive transfusion: commonly <b>Hb &lt;70 g/L, target 70-90</b> (slightly higher in IHD). <i>Confirm local threshold</i>", "Platelets if actively bleeding and &lt;50. FFP if fibrinogen &lt;1 g/L or PT/APTT &gt;1.5x normal", "<b>Warfarin:</b> PCC + IV vitamin K. <b>Dabigatran:</b> idarucizumab. <b>Apixaban/rivaroxaban</b> (life-threatening): andexanet alfa is a NICE option. Discuss with haematology", ], "4. Drugs": [ "<b>PPI before endoscopy:</b> NICE says do not offer in suspected non-variceal UGIB (many wards still do; follow local practice)", "<b>PPI after endoscopy</b> if stigmata of recent haemorrhage; high-dose IV for high-risk lesions per endoscopist", "<b>Hold:</b> NSAIDs, anticoagulants, antihypertensives if hypotensive. Consider metformin if AKI", "Secondary-prevention <b>aspirin:</b> do not stop long term; restart once haemostasis secure (senior/GI input)", "VTE prophylaxis: mechanical only while bleeding", ], "5. Suspected VARICES (chronic liver disease / alcohol)": [ "Start <b>before</b> endoscopy: <b>terlipressin</b> (check IHD/PVD) + <b>IV prophylactic antibiotics</b> (local policy, often ceftriaxone)", "Endoscopy within ~12 h of resus: <b>band ligation</b>. Gastric varices: cyanoacrylate glue", "Uncontrolled: balloon tamponade (Sengstaken/Linton) as bridge, then <b>TIPS</b>. Needs senior + ITU", "Alcohol withdrawal: chlordiazepoxide + Pabrinex. Lactulose/enema for encephalopathy risk", "INR is unreliable in cirrhosis. Don't over-transfuse", ], "6. Endoscopy timing (NICE CG141)": [ "<b>Unstable, severe bleed:</b> endoscopy immediately after resuscitation", "<b>All others:</b> within <b>24 h</b> of admission", "Refer clearly: GBS, haemodynamics, anticoagulants, comorbidity, what you have given", ], "7. After endoscopy / rebleed": [ "Follow report: PPI plan, diet, drug restart. Test and treat <b>H. pylori</b>. Avoid NSAIDs", "<b>Rebleed:</b> repeat endoscopy. Unstable after endoscopic therapy: <b>interventional radiology</b> embolisation. Then surgery", "Repeat Hb/FBC after resus and each transfusion", ], "8. Escalate NOW if": [ "SBP &lt;100 or HR &gt;100, ongoing haematemesis, raised lactate, &gt;2 units needed", "Cirrhosis, anticoagulated, or multiple comorbidities", "Airway risk (big haematemesis, low GCS): call ITU/outreach", "Document TEP/ceiling of care early in frail patients. Hourly obs and fluid balance while unstable", ], "9. Common mistakes": [ "One small cannula; late group &amp; save", "Over-fluiding cirrhotics", "Not starting terlipressin + antibiotics for possible varices", "Forgetting to hold anticoagulants/NSAIDs", "Trusting a normal Hb; vague handover with no Hb trigger, repeat bloods or escalation plan", ], } colw = (W - 2*M - 10)/2 left = ["1. ABCDE and first 15 min","2. Risk score","3. Fluids and blood","4. Drugs"] right = ["5. Suspected VARICES (chronic liver disease / alcohol)","6. Endoscopy timing (NICE CG141)","7. After endoscopy / rebleed","8. Escalate NOW if","9. Common mistakes"] def draw_col(x, keys, ytop, ybottom): y = ytop for k in keys: items = sections[k] p = Paragraph(B(items), body) w, h = p.wrap(colw-12, 2000) hdr = 14 boxh = hdr + h + 8 col = RED if ("Escalate" in k or "VARICES" in k) else NAVY c.setFillColor(LIGHT); c.roundRect(x, y-boxh, colw, boxh, 4, fill=1, stroke=0) c.setFillColor(col); c.roundRect(x, y-hdr, colw, hdr, 4, fill=1, stroke=0) c.rect(x, y-hdr, colw, 5, fill=1, stroke=0) c.setFillColor(colors.white); c.setFont("Helvetica-Bold", 8.8) c.drawString(x+6, y-10.5, k) p.drawOn(c, x+6, y-hdr-3-h) y -= boxh + 6 return y ytop = H-62 y1 = draw_col(M, left, ytop, 40) y2 = draw_col(M+colw+10, right, ytop, 40) print("left bottom", y1, "right bottom", y2) c.setFont("Helvetica-Oblique", 6.8); c.setFillColor(colors.HexColor("#555555")) c.drawString(M, 22, "Educational aid only, not a substitute for local guidelines or senior advice. Source: NICE CG141 (acute UGIB in over 16s); Tintinalli's Emergency Medicine.") c.drawString(M, 13, "Verify doses, transfusion thresholds and antibiotic choice against your trust UGIB pathway and BNF.") c.save() EOF python3 /tmp/workspace/ugib-card/make.py

Running Command

cd /tmp/workspace/ugib-card && python3 - << 'EOF' s = open("make.py").read() s = s.replace('''def B(items): return "".join(f"<bullet>&bull;</bullet>{i}<br/>" for i in items)''', '''def B(items): return [Paragraph(i, body, bulletText="\\u2022") for i in items]''') s = s.replace(''' p = Paragraph(B(items), body) w, h = p.wrap(colw-12, 2000)''',''' ps = B(items) h = 0 hs = [] for p in ps: w, ph = p.wrap(colw-12, 2000); hs.append(ph); h += ph''') s = s.replace(''' p.drawOn(c, x+6, y-hdr-3-h)''',''' yy = y-hdr-3 for p, ph in zip(ps, hs): yy -= ph p.drawOn(c, x+6, yy)''') open("make.py","w").write(s) EOF python3 make.py && python3 -c " import pdfplumber p=pdfplumber.open('/tmp/workspace/ugib-card/UGIB_Quick_Reference_Card.pdf');print(len(p.pages)) p.pages[0].to_image(resolution=80).save('/tmp/workspace/ugib-card/prev.png')"

Running Command

cd /tmp/workspace/ugib-card && sed -i 's/fontSize=7.8, leading=9.6, spaceAfter=1.2/fontSize=9.6, leading=11.8, spaceAfter=2.2/; s/"Helvetica-Bold", 8.8/"Helvetica-Bold", 10.5/; s/hdr = 14$/hdr = 17/; s/y-10.5, k/y-12.5, k/' make.py && python3 make.py && python3 -c " import pdfplumber p=pdfplumber.open('/tmp/workspace/ugib-card/UGIB_Quick_Reference_Card.pdf');print(len(p.pages)) p.pages[0].to_image(resolution=90).save('/tmp/workspace/ugib-card/prev.png')"

Loading Image
Reading File
Running Command

cd /tmp/workspace/ugib-card && sed -i 's/5. Suspected VARICES (chronic liver disease \/ alcohol)/5. Suspected VARICES (liver disease)/g; s/fontSize=9.6, leading=11.8, spaceAfter=2.2/fontSize=10.6, leading=13, spaceAfter=3/' make.py && python3 make.py && python3 -c " import pdfplumber p=pdfplumber.open('/tmp/workspace/ugib-card/UGIB_Quick_Reference_Card.pdf');print(len(p.pages)) p.pages[0].to_image(resolution=90).save('/tmp/workspace/ugib-card/prev.png')"

Reading File
Running Command

cd /tmp/workspace/ugib-card && python3 -c " import pdfplumber p=pdfplumber.open('UGIB_Quick_Reference_Card.pdf');print(len(p.pages)) p.pages[0].to_image(resolution=90).save('prev2.png')"

Reading File
Reading File
Your one-page PDF quick reference card for UGIB is ready:

UGIB Quick Reference Card

PDF Document · PDF

It is a single A4 page. The first column covers the initial ABCDE, risk score, fluids and blood, and drugs. The second column covers suspected varices, endoscopy timing, what happens after endoscopy, when to escalate, and common mistakes.
The card is based on NICE CG141 and standard UK practice. It does not give exact drug doses, and the transfusion trigger (Hb below 70 g/L, target 70-90) is the common UK default. Check doses, the transfusion threshold and antibiotic choice against your trust's UGIB pathway and the BNF before relying on it.
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