Upper gi bleeding

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