Gastrointestinal Bleed Nursing Guide

GI Bleed Classification

Upper vs Lower GI Bleed

Feature	Upper GI Bleed (UGIB)	Lower GI Bleed (LGIB)
Location	Above ligament of Treitz (oesophagus, stomach, duodenum)	Below ligament of Treitz (small bowel, colon, rectum)
Presentation	Haematemesis, melaena, coffee-ground vomit	Haematochezia (fresh rectal blood), maroon stool
Melaena	Classic — digested blood from upper source	Can occur with small bowel bleed
Frequency	More common (5:1 ratio vs LGIB)	Less common but increasing with age
Mortality	6–10% overall; up to 25% in high-risk	2–4% for acute LGIB

Warning Signs — High-Risk Features

Shock criteria: HR >100 + SBP <100 + cold clammy peripheries = haemodynamic shock. Activate massive haemorrhage protocol. Urgent resuscitation before endoscopy.

Haematemesis with fresh red blood (vs coffee-ground) — active arterial bleed
Orthostatic hypotension (SBP drop >20 on standing)
Haematocrit drop >10% acutely
Coagulopathy (cirrhosis, anticoagulants, liver disease)
Comorbidities: ischaemic heart disease (Hb <80 is dangerous), renal failure, liver cirrhosis

Upper GI Bleed Management

Common Causes

Cause	Frequency	Notes
Peptic ulcer disease (duodenal/gastric)	35–50%	H. pylori and NSAIDs main risk factors
Oesophageal varices	10–20%	Portal hypertension; very high mortality; terlipressin + band ligation
Mallory-Weiss tear	5–10%	Mucosal tear at GEJ from retching/vomiting; usually self-limiting
Oesophagitis/gastritis	10–15%	Often NSAID or alcohol-related in GCC
Dieulafoy lesion	<5%	Tortuous submucosal artery; causes massive haemorrhage; difficult to find endoscopically
Malignancy	<5%	Gastric cancer — higher in some GCC populations

Glasgow-Blatchford Score (GBS)

Pre-endoscopy risk tool to guide admission vs early discharge decision.

Variable	Value	Score
Systolic BP	100–109	1
Systolic BP	90–99	2
Systolic BP	<90	3
BUN (urea)	6.5–7.9 mmol/L	2
BUN	8–9.9 mmol/L	3
BUN	10–24.9 mmol/L	4
BUN	≥25 mmol/L	6
Haemoglobin (male)	120–129 g/L	1
Haemoglobin (male)	100–119 g/L	3
Haemoglobin (male)	<100 g/L	6
Heart rate ≥100 bpm	—	1
Melaena	—	1
Syncope	—	2
Hepatic disease	—	2
Cardiac failure	—	2

Score 0: Very low risk — consider outpatient management. Score ≥1: Hospital admission. Score ≥6: High risk — urgent endoscopy within 24 hrs.

Variceal Bleed — Special Protocol

Oesophageal varices = most dangerous UGIB. Mortality per bleed episode ~15–20%. Portal hypertension from cirrhosis.

Terlipressin 2 mg IV QDS (or octreotide 50 mcg bolus then 50 mcg/hr) — reduces portal pressure; start BEFORE endoscopy
Antibiotic prophylaxis: Ceftriaxone 1 g IV daily × 5 days (prevents bacterial peritonitis and reduces rebleeding)
Endoscopy within 12 hours: Band ligation for oesophageal varices; tissue adhesive (cyanoacrylate) for gastric varices
Avoid over-transfusion: Target Hb 70–80 g/L — over-transfusion increases portal pressure
Lactulose + rifaximin: Prevent hepatic encephalopathy from blood in gut
SB tube (Sengstaken-Blakemore): Balloon tamponade as bridge to endoscopy or TIPS in refractory bleeding; rarely used but nurses must know insertion assistance protocol

Lower GI Bleed Management

Common Causes of LGIB

Cause	Age Group	Features
Diverticular disease	Middle-aged/elderly	Painless, massive; right colon; usually stops spontaneously
Haemorrhoids	All ages	Bright red blood on paper/pan; straining; common in GCC (constipation, low fibre diet)
Angiodysplasia (AVM)	Elderly	Painless; recurrent small amounts; right colon; associated with aortic stenosis, CKD
Colorectal cancer	Middle-aged+	Change in bowel habit, weight loss; alarm feature
Inflammatory bowel disease	Young adults	Bloody diarrhoea; Crohn's/UC; associated with bloody mucus
Ischaemic colitis	Elderly, vascular	Post-prandial pain + bleeding; left colon; watershed areas

Resuscitation Protocol

Immediate Actions

Two large-bore IV cannulas (14G or 16G) — both antecubital fossae
Bloods: FBC, U&E, LFTs, coagulation, group and crossmatch (4–6 units), glucose, LDH
IV fluid resuscitation: 0.9% NaCl or Hartmann's to maintain MAP >65; avoid excessive fluids in variceal bleed
Blood transfusion: Transfuse pRBC if Hb <70 g/L (target 70–90 g/L); threshold Hb <80 g/L in ischaemic heart disease or elderly
Correct coagulopathy: FFP if PT >1.5×; platelets if <50×10⁹/L; vitamin K IV if warfarin-related
PPI: Omeprazole 80 mg IV bolus then 8 mg/hr infusion — reduces rebleeding in high-risk peptic ulcer (UGIB only; not varices)
Monitor: Hourly urine output, continuous cardiac monitoring, serial Hb 4-hourly
NBM: For endoscopy — nothing by mouth from presentation

Transfusion Strategy

Restrictive transfusion (Hb threshold 70 g/L) is superior to liberal transfusion in most GI bleed patients. Exception: active ischaemic heart disease → transfuse at Hb <80 g/L.

Patient	Transfuse when Hb	Target Hb
General UGIB	<70 g/L	70–90 g/L
Cardiac disease / elderly	<80 g/L	80–100 g/L
Variceal bleed (cirrhosis)	<70 g/L	70–80 g/L (avoid over-transfusion)
Massive haemorrhage (>4 units in 4 hrs)	Activate MHP	1:1:1 (RBC:FFP:platelets)

GCC-Specific Context

GI Bleed in GCC

H. pylori prevalence: Very high in GCC (50–70% seroprevalence) — primary driver of peptic ulcer disease and ulcer bleeding. H. pylori eradication after peptic ulcer bleed is mandatory to prevent recurrence
NSAID use: High use of NSAIDs (ibuprofen, diclofenac) — often purchased over-the-counter in GCC without PPI co-prescription. NSAIDs are the second leading cause of peptic ulcer bleed. Education campaigns ongoing across GCC pharmacies
Liver cirrhosis: Hepatitis C (Egypt-origin GCC residents), hepatitis B (endemic in some GCC national populations), NAFLD from metabolic syndrome — portal hypertension and variceal bleed increasing in GCC hepatology units
Anticoagulant-related GIB: Rapid uptake of DOACs (rivaroxaban, apixaban) for AF in GCC — anticoagulant-related GI bleed increasing. Reversal agents (andexanet alfa) now available in major GCC centres
Ramadan: NSAID use increases for Hajj-related musculoskeletal complaints. Patients often self-medicate and present with peptic ulcer bleeding during/after Ramadan

Exam Tips

Blatchford score 0 = low risk; may discharge from ED
Haematemesis + melaena = UGIB until proven otherwise
Variceal bleed: terlipressin + antibiotic (ceftriaxone) + band ligation
PPI infusion (omeprazole) for peptic ulcer bleed — NOT for varices
Transfusion threshold: Hb <70 (80 in cardiac); avoid over-transfusion in varices
H. pylori eradication after peptic ulcer bleed = prevents recurrence

Exam MCQs — DHA / SCFHS / QCHP

Q1. A patient presents with haematemesis. HR is 112 bpm, BP 88/60 mmHg. What is the FIRST priority nursing action?

A) Arrange urgent upper GI endoscopy B) Establish two large-bore IV cannulas, start IV fluid resuscitation and send urgent bloods including crossmatch C) Administer oral sucralfate and bed rest D) Insert NG tube for gastric lavage

✅ B — The patient is in haemorrhagic shock (HR >100, SBP <90). Resuscitation takes priority over endoscopy. Two large-bore cannulas, aggressive IV fluids, crossmatch blood, monitoring. Endoscopy happens after haemodynamic stabilisation. NG lavage is no longer recommended.

Q2. A patient with liver cirrhosis presents with haematemesis from oesophageal varices. Haemoglobin is 65 g/L. What blood transfusion strategy is CORRECT?

A) Transfuse aggressively to Hb >100 g/L — more blood is better in variceal bleed B) Transfuse to Hb 70–80 g/L — restrictive strategy; over-transfusion worsens portal hypertension C) Do not transfuse — cirrhotic patients cannot tolerate blood transfusion D) Transfuse only if Hb <50 g/L in variceal bleed

✅ B — In variceal bleed, restrictive transfusion (Hb target 70–80 g/L) is essential. Over-transfusion increases portal pressure and splanchnic blood flow, worsening variceal pressure and increasing rebleeding risk. The TRANSFUSION trial showed restrictive strategy improved survival in cirrhotic upper GI bleed.

Q3. A patient with oesophageal variceal bleed has been started on terlipressin. What is the PRIMARY mechanism of action of terlipressin?

A) Direct vasoconstriction of oesophageal varices B) Reduction of portal venous pressure by splanchnic vasoconstriction C) Inhibition of gastric acid secretion D) Stimulation of platelet aggregation at bleeding site

✅ B — Terlipressin (vasopressin analogue) causes splanchnic arterial vasoconstriction, reducing blood flow to the portal system and thereby lowering portal venous pressure. This reduces variceal bleeding pressure. It also has direct vasoconstrictive effects on vascular smooth muscle.

Q4. A patient taking warfarin for AF presents with haematemesis. INR is 5.2. What is the CORRECT reversal strategy?

A) Stop warfarin and await INR correction — no active reversal needed B) Vitamin K 5–10 mg IV + 4-factor prothrombin complex concentrate (4F-PCC) for urgent reversal C) Fresh frozen plasma only — preferred reversal for warfarin D) Protamine sulphate IV — specific warfarin reversal agent

✅ B — Urgent warfarin reversal in life-threatening bleeding: Vitamin K 5–10 mg IV (slow onset 6–8 hrs) PLUS 4-factor PCC (Octaplex/Beriplex) for immediate INR reversal within minutes. FFP alone requires large volumes and takes longer. Protamine reverses heparin, NOT warfarin.

🩸 Gastrointestinal Haemorrhage