Upper gi bleeding

8 min read Last updated April 9, 2026

Surgical approach (what happens clinically)

  • Most cases managed with endoscopy, surgery is rescue therapy when endoscopy/IR fails or patient remains unstable
    • Diagnostic OGD ± therapeutic: adrenaline injection, thermal coagulation, clips, haemostatic powder
    • Variceal bleeding: band ligation (oesophageal) or cyanoacrylate injection (gastric) ± balloon tamponade as bridge
  • If ongoing bleeding despite endoscopy: interventional radiology (arterial embolisation) where available
    • Common targets: gastroduodenal artery, left gastric artery, requires contrast, anticoagulation considerations, post-embolisation ischaemia risk
  • Surgery (rare but high-risk): oversew bleeding ulcer ± vagotomy/pyloroplasty (less common now) or partial gastrectomy, for varices: shunt/TIPS usually preferred over open surgery
    • Indications: refractory bleeding, haemodynamic instability, inability to access/perform endoscopy/IR, suspected perforation/malignancy

Anaesthetic management (endoscopy/IR/surgery)

  • Type of anaesthesia: usually GA for unstable patients, active haematemesis, anticipated prolonged/therapeutic OGD, IR embolisation, or surgery
    • Sedation (propofol ± opioid) only for stable, fasted, low aspiration risk diagnostic OGD, avoid deep sedation in ongoing haematemesis
  • Airway: ETT preferred in active bleeding/aspiration risk, consider RSI with suction-ready, SGA generally inappropriate in active UGIB
    • Positioning: head-up where feasible, aggressive suction, consider large-bore orogastric tube only if requested/appropriate (may hinder endoscopy)
  • Duration: OGD typically 20–60 min, IR 1–3 h, surgery variable 1–3+ h depending on procedure and instability
  • Pain: OGD minimal, IR mild-moderate, surgery moderate-severe (upper abdominal incision) → multimodal analgesia but avoid hypotension/respiratory depression
    • Regional: neuraxial techniques usually avoided in shocked/coagulopathic patients, consider TAP blocks/rectus sheath blocks as adjuncts if coagulation acceptable
  • Key priorities: resuscitate first, correct coagulopathy, maintain oxygen delivery, prevent aspiration, early senior help, activate major haemorrhage protocol (MHP) when indicated

Definition and scope

  • Upper GI bleed = bleeding proximal to ligament of Treitz (oesophagus, stomach, duodenum)
  • Presentations: haematemesis, coffee-ground vomit, melaena, brisk UGIB can present with haematochezia and shock

Aetiology (common + exam-relevant)

  • Non-variceal (most common): peptic ulcer disease (gastric/duodenal), erosive gastritis/duodenitis, oesophagitis, Mallory–Weiss tear, malignancy, Dieulafoy lesion
  • Variceal: portal hypertension (cirrhosis), oesophageal/gastric varices, portal hypertensive gastropathy
  • Drug-related: NSAIDs, antiplatelets, anticoagulants, SSRIs (risk), steroids (with NSAIDs)

Immediate assessment and resuscitation (A–E)

  • Call for help early: senior anaesthetist, endoscopist, ICU, transfusion lab, consider IR and surgery early if unstable
  • Airway/Breathing: high-flow O2, suction, assess aspiration risk, early intubation if ongoing haematemesis, reduced GCS, severe shock, or need for urgent therapeutic endoscopy
    • Pre-oxygenate, consider apnoeic oxygenation, prepare for difficult airway (blood obscures view)
  • Circulation: 2 x large-bore IV (14–16G) or rapid infuser, consider arterial line early, send bloods and crossmatch
    • Bloods: FBC, U&amp,E, LFT, coagulation, fibrinogen, VBG/ABG with lactate, group &amp, save/crossmatch, calcium
  • Fluids/blood: permissive approach until haemostasis but maintain perfusion, activate MHP if haemodynamic instability with suspected major bleed
    • Transfusion targets (typical): Hb 70–90 g/L (higher if ACS/ongoing ischaemia), platelets &gt,50 (or &gt,100 if massive/ongoing), fibrinogen &gt,1.5–2.0 g/L, correct hypocalcaemia
  • Disability/Exposure: check GCS, glucose, temperature, prevent hypothermia (warming, fluid warmer)

Risk stratification and escalation

  • Use Glasgow-Blatchford Score (GBS) pre-endoscopy to predict need for intervention, low risk may be outpatient
    • GBS uses: urea, Hb, systolic BP, pulse, melaena, syncope, hepatic disease, cardiac failure
  • Post-endoscopy: Rockall score (clinical + endoscopic) predicts rebleeding/mortality
  • Timing of endoscopy: after resuscitation, urgent (often within 24 h) for most, immediate for ongoing haemodynamic instability despite resuscitation

Medical management (before/around endoscopy)

  • Non-variceal suspected: PPI (e.g., IV omeprazole) commonly used, definitive therapy is endoscopic haemostasis
  • Variceal suspected (cirrhosis/portal HTN): start terlipressin and antibiotics (e.g., ceftriaxone) early, plan endoscopic banding
    • Terlipressin cautions: ischaemia, hyponatraemia, monitor ECG, sodium, perfusion
  • Tranexamic acid: not routine for UGIB (evidence does not support routine use), follow local policy
  • Reversal of anticoagulation (balance thrombosis vs bleeding, involve haematology):
    • Warfarin: IV vitamin K + PCC for major bleeding
    • DOACs: consider andexanet alfa (Xa inhibitors) or idarucizumab (dabigatran) where indicated/available, otherwise PCC may be used
    • Antiplatelets: discuss with cardiology if recent stent/ACS, platelet transfusion generally not routine unless life-threatening bleeding or urgent surgery

Anaesthetic technique for urgent OGD in UGIB

  • Pre-op: resuscitate, correct coagulopathy, ensure blood available, consent/communication, aspiration prophylaxis if time (e.g., sodium citrate) but do not delay life-saving intervention
  • Monitoring: standard + consider arterial line pre-induction if unstable, large-bore access, consider central access for rapid infusion/vasopressors
  • Induction: treat as full stomach, RSI with head-up, suction x2, choose haemodynamically stable agents (e.g., ketamine/etomidate depending on context) and early vasopressor support
    • Vasopressors: metaraminol/phenylephrine boluses, noradrenaline infusion early in profound shock
  • Maintenance: volatile or TIVA, avoid hypotension, maintain normothermia, frequent Hb/ABG checks in major bleed
  • Extubation: only if haemostasis achieved, minimal ongoing bleeding, stable physiology, low aspiration risk, otherwise ventilate to ICU

Special considerations: cirrhosis/variceal bleeding

  • Physiology: hyperdynamic circulation, low SVR, cardiomyopathy, coagulopathy (rebalanced haemostasis), thrombocytopenia, encephalopathy, ascites, renal dysfunction
  • Drug handling: reduced hepatic clearance, increased sensitivity to sedatives/opioids, avoid long-acting benzodiazepines, consider encephalopathy risk
  • Coagulation: INR may not reflect bleeding risk, use clinical picture ± viscoelastic testing if available, correct fibrinogen/platelets pragmatically in active bleeding
  • Rescue/bridge: balloon tamponade (Sengstaken–Blakemore/Minnesota) requires airway protection and ICU, definitive therapy often endoscopic ± TIPS

Complications

  • Haemorrhagic shock → myocardial ischaemia, AKI, gut ischaemia, aspiration pneumonitis/pneumonia
  • Transfusion complications: hypocalcaemia, hypothermia, dilutional coagulopathy, TRALI/TACO, hyperkalaemia, citrate toxicity
  • Procedure-related: perforation, rebleeding, post-embolisation ischaemia (IR), airway trauma/difficult intubation due to blood

Test yourself…

You are called to ED for a 58-year-old with massive haematemesis, BP 75/40, HR 135. Talk through your immediate management.

Structure: A–E, resuscitate, activate systems, plan definitive haemostasis.

  • Call for help: senior anaesthetist, endoscopist, ICU, transfusion, consider IR/surgery early
  • A/B: high-flow O2, suction, assess need for early intubation (ongoing haematemesis/shock/low GCS) to protect airway and facilitate endoscopy
  • C: 2 large-bore IV/IO, arterial line if feasible, send bloods (FBC, coag, fibrinogen, U&amp,E/LFT, ABG lactate, crossmatch)
  • Activate MHP if major ongoing haemorrhage, transfuse RBC/FFP/platelets guided by protocol and labs, give calcium, warm patient/fluids
  • Start targeted meds: PPI if non-variceal likely, if cirrhosis/varices suspected start terlipressin + antibiotics
  • Definitive: urgent therapeutic OGD once resuscitated, if fails → IR embolisation or surgery
How would you decide whether a patient with UGIB needs admission and urgent endoscopy?

Use risk scores + clinical judgement, resuscitation status overrides scoring.

  • Use Glasgow-Blatchford Score pre-endoscopy to identify low-risk patients (possible outpatient management if very low score and stable)
  • High-risk features: shock, ongoing haematemesis, syncope, significant comorbidity (IHD/heart failure), Hb drop, high urea, anticoagulation
  • Timing: endoscopy after initial resuscitation, urgent if unstable or ongoing bleeding
Describe your anaesthetic plan for emergency OGD in a patient with active haematemesis.

Aim: protect airway, maintain perfusion/oxygen delivery, enable endoscopic haemostasis.

  • Treat as full stomach with high aspiration risk → GA with cuffed ETT, avoid SGA
  • Preparation: suction ready (ideally 2), head-up, rapid infuser/blood available, vasopressors drawn up, difficult airway plan
  • Induction: RSI, choose induction agent to match physiology (e.g., ketamine/etomidate), early noradrenaline if profound shock
  • Intra-op: invasive BP if unstable, frequent ABG/Hb, active warming, transfusion guided by MHP/labs
  • Post-op: extubate only if stable and bleeding controlled, otherwise ICU ventilation
What are the key differences in management between variceal and non-variceal UGIB?

Both need resuscitation and endoscopy, variceal bleeding has specific vasoactive and antibiotic therapy and different endoscopic techniques.

  • Variceal: terlipressin early + antibiotics, endoscopy with band ligation (oesophageal) / glue (gastric), consider TIPS if refractory
  • Non-variceal: PPI commonly used, endoscopic injection/thermal/clips, consider IR embolisation or surgery if fails
  • Cirrhosis considerations: encephalopathy, ascites, renal dysfunction, altered drug handling, complex haemostasis
Outline your transfusion strategy in major UGIB.

Use MHP when appropriate, avoid under-resuscitation and avoid iatrogenic coagulopathy/hypocalcaemia/hypothermia.

  • If shocked with suspected major haemorrhage: activate MHP with balanced components per local protocol, do not wait for lab confirmation
  • Targets: Hb often 70–90 g/L (individualise: higher if ACS), platelets &gt,50 (or &gt,100 if massive/ongoing), fibrinogen &gt,1.5–2.0 g/L
  • Give calcium during massive transfusion, warm patient/fluids, monitor K+, acid-base, temperature
A patient on warfarin presents with UGIB and haemodynamic instability. How do you reverse anticoagulation?

Major bleeding requires rapid reversal while arranging definitive haemostasis.

  • Give PCC for rapid reversal + IV vitamin K to sustain reversal
  • Send INR but do not delay PCC in life-threatening bleeding, reassess after treatment
  • Balance thrombosis risk, involve haematology/cardiology as appropriate
What are the anaesthetic implications of cirrhosis in variceal bleeding?

Expect haemodynamic instability, altered pharmacology, and multi-organ dysfunction.

  • Haemodynamics: low SVR, high CO, prone to hypotension on induction → vasopressors early
  • Coagulation: thrombocytopenia, low fibrinogen, INR unreliable, consider viscoelastic testing if available
  • CNS: encephalopathy risk—minimise sedatives, consider postoperative ventilation/ICU
  • Renal: hepatorenal risk—avoid nephrotoxins, maintain perfusion, careful fluid strategy
How would you manage a patient who continues to bleed despite endoscopic therapy?

Escalate to IR/surgery, maintain resuscitation and reassess airway/ICU needs.

  • Reassess haemodynamics, activate/continue MHP, correct coagulopathy, ensure airway protection
  • Escalate to IR embolisation if available and appropriate
  • If IR not available/failed or patient unstable: proceed to surgery (e.g., oversew ulcer) with ICU-level perioperative support
List complications of massive transfusion relevant to UGIB and how you mitigate them.

Think metabolic, respiratory, circulatory, immunological.

  • Hypocalcaemia (citrate) → give IV calcium, monitor ECG/ionised Ca
  • Hypothermia → active warming, fluid warmers, warmed blood
  • Coagulopathy/dilution → balanced components, check fibrinogen/platelets, consider viscoelastic testing
  • TACO/TRALI → careful volume assessment, ventilatory support, involve ICU, avoid unnecessary transfusion
  • Hyperkalaemia/acidosis → monitor ABG/electrolytes, treat promptly
A patient with UGIB is agitated and hypoxic with ongoing haematemesis. What are your indications for intubation and what are your key steps?

Indications are clinical: airway protection and facilitating haemostasis.

  • Indications: reduced consciousness, inability to protect airway, ongoing large-volume haematemesis, severe hypoxia/respiratory failure, profound shock, need for urgent therapeutic endoscopy
  • Key steps: head-up, suction x2, pre-oxygenate, RSI, early vasopressors, confirm ETT with capnography, secure tube, consider ICU post-procedure

0 comments