GI Bleeding — GCC Nursing Guide

Emergency Priority: GI bleeding is a medical emergency. Simultaneous resuscitation and assessment are required. Call for senior support early — do not delay.

🔴 Upper vs Lower GI Bleed Differentiation

Presentation	Likely Source	Key Points
Haematemesis (vomiting blood)	UGIB	Bright red = active bleeding; coffee-ground = altered blood (slower/older). Ligament of Treitz is anatomical divide.
Melaena (black, tarry stools)	Usually UGIB	Requires ~50ml blood in upper GI. Can also occur with small bowel or slow right-sided LGIB. Distinctive offensive odour.
Haematochezia (fresh rectal bleeding)	Usually LGIB	Bright or dark red PR blood. If massive UGIB (>1L), can present as haematochezia — always consider.
Occult bleeding	Either	Iron-deficiency anaemia, positive faecal occult blood test, no visible bleeding.

Pitfall: Haematochezia does NOT always mean LGIB. Massive UGIB with rapid transit can present as bright red PR bleeding. Insert NG tube if uncertain and patient is haemodynamically unstable.

🧪 ABCDE Assessment Framework

Airway: Risk of aspiration (vomiting, reduced consciousness, hepatic encephalopathy). Position: left lateral. Consider airway protection before endoscopy if haematemesis.
Breathing: SpO2, RR. Anaemia causes compensatory tachypnoea. O2 therapy if SpO2 <94%.
Circulation: HR, BP, capillary refill, peripheries. Postural BP drop ≥20mmHg systolic = significant haemodynamic compromise. Insert 2× large-bore IVs (14–16G).
Disability: GCS — hepatic encephalopathy? Syncope history? Pain assessment.
Exposure: Full skin examination (spider naevi, jaundice = liver disease), abdominal exam, digital rectal examination — colour and consistency of stool, clots.

Haemodynamic Stability Assessment

Parameter	Stable	Unstable (Shocked)
Heart Rate	<100 bpm	>100 bpm — tachycardia is early sign
SBP	>100 mmHg	<100 mmHg (active shock)
Postural drop	<20 mmHg change	≥20 mmHg = 15–20% volume loss
Urine output	>0.5 ml/kg/h	<0.5 ml/kg/h = reduced perfusion
Consciousness	Alert, orientated	Confusion, agitation, drowsiness
Capillary refill	<2 seconds	>2 seconds, cool peripheries

📊 Rectal Examination & Stool Documentation

DRE Findings

Fresh bright red blood: anorectal / LGIB source likely
Dark red/clots: left colon, rapid UGIB
Melaena on glove: UGIB until proven otherwise
Hard stool + streaks: haemorrhoids, fissure
Mass felt: rectal carcinoma — urgent referral

Stool Chart Documentation

Bristol Stool Chart type + colour (black / dark / red / mixed)
Volume estimate (teaspoon / cup / toilet pan)
Presence of clots, mucus
Time and frequency
Associated symptoms: pain, tenesmus, urgency

Glasgow-Blatchford Score (GBS) Calculator

GBS 0 = safe for outpatient management. GBS ≥1 = inpatient endoscopy required. GBS ≥6 = high risk, urgent endoscopy.

Blood Urea (mmol/L)

Haemoglobin — Male (g/dL)

Haemoglobin — Female (g/dL)

Systolic BP (mmHg)

Heart Rate

Melaena at Presentation

Syncope at Presentation

Hepatic Disease

Cardiac Failure

Rockall Score Calculator (Pre-Endoscopy)

Pre-endoscopy score uses age, haemodynamic state, and comorbidity. Score ≥5 = high risk for 30-day mortality.

Age

Haemodynamic State (Shock)

Comorbidity

🔬 Common Causes of UGIB

Cause	Frequency	Key Features
Peptic Ulcer Disease (gastric/duodenal)	35–50%	H. pylori, NSAIDs, aspirin. Forrest classification guides endoscopic treatment.
Oesophagogastric varices	~20%	Portal hypertension (cirrhosis). High mortality 15–30% per episode. Requires specialist pathway.
Mallory-Weiss tear	5–10%	Longitudinal mucosal tear at GOJ after retching/vomiting. Usually self-limiting.
Oesophagitis / GORD	5–15%	Usually slow ooze. PPI therapy effective.
Dieulafoy lesion	<5%	Dilated submucosal vessel, fundus. Difficult to find; may need multiple endoscopies.
GAVE (Gastric Antral Vascular Ectasia)	<5%	"Watermelon stomach." Associated with liver disease, connective tissue disorders.
Malignancy	2–4%	Gastric/oesophageal cancer. Often chronic, iron-deficiency anaemia picture.

💊 PPI Therapy Protocol

High-risk stigmata (Forrest Ia, Ib, IIa, IIb): IV Omeprazole 80mg bolus over 30 min, then 8mg/h infusion for 72 hours post-endoscopy. Reduces rebleeding and mortality.

High-Risk Forrest Features

Ia: Spurting arterial haemorrhage
Ib: Oozing haemorrhage
IIa: Non-bleeding visible vessel
IIb: Adherent blood clot

Lower-Risk Forrest Features

IIc: Flat pigmented spot — PO PPI, discharge possible
III: Clean base ulcer — PO PPI, early discharge
Oral PPI (omeprazole 40mg OD or BD) for 4–8 weeks
H. pylori eradication if positive

Nursing Actions for PPI Infusion

Mix omeprazole 8mg/h in compatible diluent (0.9% NaCl or 5% dextrose) — check local protocol
Dedicated IV line preferred (incompatible with many drugs)
Monitor IV site for phlebitis (alkaline solution)
Document rate, start time, cumulative dose every shift
Oral switch after 72h if haemostasis confirmed and tolerating oral

🩸 Variceal Bleeding Management

Critical: Variceal bleeding mortality is 15–30% per episode. This requires a coordinated multi-disciplinary approach: gastroenterology, hepatology, IR, and ICU involvement.

Pharmacological Management (start immediately)

Terlipressin 2mg IV every 4–6h (reduces portal pressure) — monitor BP, heart rate, ischaemic symptoms; contraindicated in severe IHD
Prophylactic antibiotics: Ceftriaxone 1g IV OD × 5–7 days (or ciprofloxacin). Reduces spontaneous bacterial peritonitis and mortality.
Lactulose: Prevents hepatic encephalopathy from blood protein load in gut

Endoscopic Treatment (within 12h of presentation)

Band ligation (EVL): First-line for oesophageal varices. Bands placed at base of varix. Repeat every 2–4 weeks until obliteration.
Sclerotherapy: Alternative if ligation not feasible. Ethanolamine or sodium tetradecyl injected. Risk: ulceration, stricture, bacteraemia.
Gastric varices: Cyanoacrylate glue injection or TIPS (no band ligation — risk of torrential bleed)

Refractory Bleeding — Salvage Options

TIPS (Transjugular Intrahepatic Portosystemic Shunt): Indicated if 2 endoscopic treatments fail. IR procedure. Reduces portal pressure by 50–60%. Risk of encephalopathy post-procedure.
Sengstaken-Blakemore Tube: Temporary bridge only (24–48h maximum) while awaiting TIPS or transfer. ICU nurse-to-patient 1:1 mandatory.
Surgical portosystemic shunt: Rarely used in current practice.

Sengstaken-Blakemore Tube — Nursing Protocol

High-risk procedure: Risk of oesophageal rupture, aspiration, and asphyxiation. Requires ICU setting, intubation usually recommended, 1:1 nursing.

Confirm intubation (most centres intubate first to protect airway)
Lubricate tube; insert to 50cm mark (confirmed by X-ray before inflation)
Inflate gastric balloon with 250ml air — confirm position on CXR
Apply traction (1kg weight over pulley / traction device) — maintains balloon at GOJ
If bleeding continues: inflate oesophageal balloon to 30–40 mmHg using manometer
Deflate oesophageal balloon for 30 min every 12 hours (prevent pressure necrosis)
Aspirate gastric and oesophageal ports every hour — document volume and colour
Scissors at bedside at all times — cut tube immediately if airway emergency
Maximum duration: 24–48h. Arrange definitive treatment (TIPS/OGD) before removal.

🔍 Common Causes of LGIB

Cause	Notes	Age Group
Diverticular disease — most common	Painless, arterial, can be massive. Usually right-sided diverticula bleed. 80% stop spontaneously.	Middle-aged / Elderly
Angiodysplasia	Ectatic vessels, caecum/right colon. Chronic or acute. Associated with aortic stenosis, renal failure.	Elderly
Colitis (IBD/infective/ischaemic)	IBD: bloody diarrhoea + pain + fever. Ischaemic: post-vascular event, "watershed areas" (splenic flexure).	Any
Haemorrhoids	Bright red blood coating stool / on tissue. Rarely causes haemodynamic compromise.	Any
Colorectal cancer	Occult or overt. Change in bowel habit, weight loss, anaemia. Urgent 2-week referral pathway.	>50 years
Meckel's diverticulum	Ectopic gastric mucosa causes ulceration. "Rule of 2s": 2% population, 2ft from ileocaecal valve, 2% symptomatic.	Children / Young adults
Anal fissure	Sharp pain with defaecation + bright red blood. Often with constipation.	Any

🔭 Colonoscopy & Imaging Pathway

Urgent Colonoscopy

Within 24 hours of haemodynamic stabilisation for significant LGIB
Bowel prep required (PEG solution 4–6L over 3–4h via NG if unable to drink)
Treat: clip / argon plasma coagulation (APC) / injection therapy
Diagnostic yield highest in first 24h

CT Angiography

Detects active bleeding rate >0.5 ml/min
Fast — useful in haemodynamically unstable patient before colonoscopy
Guides IR embolisation target vessel
No bowel prep required

Interventional Radiology

Selective mesenteric angiography + embolisation
Detects bleeds >0.5–1 ml/min
Success rate 80–90% in active diverticular bleed
Risk: bowel ischaemia (~5%), post-procedure monitoring essential
Monitor: abdominal pain, peritonism, temperature, stool

Surgery (Last Resort)

Persistent or recurrent haemorrhage not amenable to endoscopy or IR
Segmental resection preferred if source localised
Subtotal colectomy if source not found — high morbidity
Surgical consent and pre-op prep essential before IR fails

🏥 Haemorrhoid Management & Post-Op Nursing

Non-Operative Management

Rubber band ligation (RBL): outpatient procedure. Warn: discomfort / mild rectal bleeding 3–7 days post-procedure. Avoid NSAIDS for 5 days.
Dietary advice: high-fibre diet, adequate hydration, stool softeners (lactulose / docusate)
Topical agents: lidocaine / hydrocortisone creams for symptom relief

Haemorrhoidectomy Post-Op Nursing

Pain management: Multimodal analgesia — regular paracetamol, NSAIDS (if tolerated), topical anaesthetic cream. PCA or regional if severe.
Sitz baths: Warm water 15–20 min TDS — reduces anal sphincter spasm, aids healing. Start 24h post-op.
Stool softeners: Lactulose 15–30ml BD or macrogol. Aim for soft stool at day 2–3. Avoid straining.
Urinary retention: Common (10–20%) — monitor urine output, bladder scan at 6h if no void. Intermittent catheterisation if retention.
Secondary haemorrhage: Risk at 7–10 days (when bands/scabs separate). Educate patient — return to ED if soaking pad in <20 min.
Diet: High fibre immediately post-op. Oral fluids early. Avoid low-residue diet.

Immediate Actions: 2× large-bore IV access (14–16G) → bloods → IV fluid / blood as required → monitoring → senior review and endoscopy team activation.

💉 IV Access & Initial Bloods

IV Access

Minimum 2× large-bore peripheral IVs (14–16G) — antecubital fossa
Central venous access (triple lumen) if peripheral access fails or continuous monitoring needed
Arterial line in ICU/HDU patients for continuous BP monitoring
IDC: hourly urine output monitoring — target >0.5 ml/kg/h

Essential Blood Tests

FBC: Hb, WBC, platelets
Coagulation: PT/INR, APTT, fibrinogen
Group & screen + crossmatch (4 units minimum for major bleed)
U&E / LFTs / glucose
Lactate: marker of tissue hypoperfusion (>2 mmol/L = significant)
ABG: base deficit, pH, pCO2

🩸 Blood Transfusion Strategy

Restrictive Strategy: Transfuse when Hb <7 g/dL. Target Hb 7–9 g/dL. In variceal bleeding, restrictive transfusion (target 7–8) reduces portal pressure, rebleeding risk, and mortality. Over-transfusion worsens portal hypertension.

Patient Group	Transfusion Threshold	Target Hb
Standard GI bleed	Hb <7 g/dL	7–9 g/dL
Variceal bleeding	Hb <7 g/dL (strict restrictive)	7–8 g/dL only
ACS / cardiac patients	Hb <8 g/dL	8–10 g/dL
Massive haemorrhage	Immediate O-neg if life-threatening	Activate MTP, target Hb >8

Coagulopathy Correction

FFP: If INR >1.5 and active bleeding — 12–15 ml/kg (approximately 4 units in average adult). Takes 30–45 min to prepare.
Platelets: Transfuse if platelets <50×10⁹/L with active bleeding. Target >50 in ongoing haemorrhage. >100 if intracranial involvement.
Vitamin K: 10mg IV slow push for warfarin reversal (takes 6–12h to work). For immediate reversal: Prothrombin Complex Concentrate (PCC) preferred over FFP.
Cryoprecipitate: If fibrinogen <1.5 g/L. 2 pools (10 units) typically.
Tranexamic acid (TXA): 1g IV over 10 min — for massive haemorrhage. Best within 3 hours of bleeding onset. Antifibrinolytic — reduces clot breakdown.
DOAC reversal: Idarucizumab (for dabigatran), Andexanet alfa (for factor Xa inhibitors) — specialist haematology guidance required.

Massive Transfusion Protocol (MTP) — 1:1:1 Ratio

Activate MTP when: transfusion of ≥10 units pRBC in 24h anticipated, or active haemorrhage with haemodynamic instability unresponsive to initial fluids.

Pack Red Blood Cells : Fresh Frozen Plasma : Platelets = 1:1:1
Monitor calcium (hypocalcaemia from citrate in blood products) — give calcium gluconate 10ml per 4 units
Monitor temperature — use blood warmer, warm environment (hypothermia worsens coagulopathy)
Point-of-care testing: TEG/ROTEM if available to guide product choice
Haematology liaison essential for ongoing MTP activation

💧 Fluid Resuscitation

Balanced crystalloids preferred (Hartmann's / Plasma-Lyte): avoid large volumes of 0.9% NaCl (hyperchloraemic acidosis worsens coagulopathy)
Limit crystalloids to 500ml–1L bolus initially — excessive crystalloids dilute clotting factors and worsen coagulopathy ("lethal triad": acidosis + hypothermia + coagulopathy)
In variceal bleeding: avoid over-resuscitation — increases portal pressure. Target MAP 65–70 mmHg.
Colloids (albumin, Gelofusine): no proven mortality benefit over crystalloids in GI bleed. Albumin 20% may be used in liver disease for intravascular expansion.
Monitor for fluid overload: crackles, SpO2 drop, rising CVP — especially in elderly and cardiac patients

🔭 Emergency OGD — Pre-Procedure Preparation

ABCs first: Ensure airway protected (especially vomiting patients or encephalopathic liver disease). Consider anaesthetic review for intubation before scope.
IV Access confirmed: 2× large-bore IVs patent, running fluids. Emergency drugs drawn up.
Blood products available: Crossmatched blood in fridge on the ward / theatre. FFP and platelets available if variceal bleed likely.
NPO status documented: Minimum 2h liquids, 4h light food. In emergency, delay is not always possible — document and inform endoscopist.
Patient positioning: Left lateral position for OGD (gravity keeps blood pool in fundus, away from pylorus). Jaw support and suction ready for vomiting.
Consent: Verbal consent minimum — document capacity. Written consent if time allows. Interpreter services for language barriers (common in GCC).
Pre-medication: Erythromycin 250mg IV 30–60 min before OGD improves visualisation by accelerating gastric emptying (prokinetic effect).
Throat spray: Lidocaine 10% spray — document allergy status. 2 puffs to posterior pharynx.
Sedation preparation: Midazolam + fentanyl standard. Liver disease: reduce doses by 50% (impaired metabolism, encephalopathy risk). Flumazenil and naloxone at bedside (reversal agents).

📡 Monitoring During Endoscopy

Continuous Monitoring Required

SpO2: Target >94%. O2 via nasal cannula 2–4L/min throughout procedure. Desaturation = suction, jaw lift, O2 increase, pause scope.
Heart Rate: Vasovagal response common. Tachycardia = ongoing bleed. Bradycardia = vasovagal.
Blood Pressure: NIBP every 3–5 minutes.
Consciousness: Verbal response, eye opening. AVPU scale. Sedation scoring (e.g., Ramsay).

Sedation Risk in Liver Disease

Cirrhosis alters pharmacokinetics of benzodiazepines and opioids — prolonged sedation, paradoxical excitation, precipitation of encephalopathy. Reduce doses by 50% or use propofol with anaesthetic team.

Flumazenil 0.2mg IV (reversal) — at bedside at all times
Naloxone 0.4mg IV/IM (opioid reversal) — at bedside

🧬 Specimen Management

H. pylori biopsy: 2 biopsies from antrum + 1 from corpus (Sydney protocol). Send in formalin for histology. Rapid urease test (CLO test) for same-day result. Inform endoscopist if patient on recent antibiotics or PPI (false negatives).
Polyp specimens: Label individually by site and number (e.g., "polyp 1 — sigmoid colon at 25cm"). Separate pots in formalin. Matching pathology request form essential.
Brushings / aspirates: Cytology specimens in appropriate fluid — cytofix or ethanol depending on lab protocol. Urgent if malignancy suspected.
Documentation: Specimen number, site, type (biopsy/brushing), time taken, sent to which lab, chain of custody maintained.

📋 Post-Procedure Monitoring — Haemostasis Check

Post-Endoscopy Observation: Vital signs every 30 minutes × 4 hours post-procedure minimum. Then hourly if stable. ICU/HDU for high-risk patients (varices, Forrest Ia/Ib, haemodynamically unstable).

General Post-Procedure Checks

Observe stool colour — melaena persisting after UGIB haemostasis can be old blood (not necessarily rebleed). Fresh haematemesis or haemodynamic deterioration = rebleed.
Heart rate trend — rising HR is sensitive early sign of rebleed
Abdominal pain — new or worsening pain post-colonoscopy = perforation until proven otherwise (urgent surgical review)
Bowel sounds documentation post-colonoscopy

Post-Sclerotherapy Specific

Chest pain and dysphagia are expected and common in 24–48h after oesophageal sclerotherapy (chemical oesophagitis). Reassure patient. Analgesia as required. If severe chest pain + fever: exclude oesophageal perforation (CXR, surgical review).

Post-Band Ligation Specific

Avoid NSAIDs for 10 days — risk of ulceration at band sites causing delayed bleeding
Delayed bleeding risk: 5–7 days post-banding (when bands/ulcers slough). Educate patient. Return immediately if haematemesis or melaena.
Soft diet for 48h post-banding
Non-selective beta-blocker (propranolol / carvedilol) initiated as secondary prophylaxis — titrate to resting HR 55–60 bpm

🌍 GCC-Specific Risk Factors & Epidemiology

H. pylori in GCC

H. pylori seroprevalence in South Asian and Southeast Asian expatriate workers (who form the majority of GCC manual labour workforce) ranges from 60–80% in some studies. High crowding in labour camps, shared facilities, and poor sanitation in home countries drives transmission. This translates to high rates of peptic ulcer disease and UGIB in this demographic.

Test all UGIB patients for H. pylori regardless of age (CLO test / serology / stool antigen)
Eradication therapy: Triple therapy (PPI + clarithromycin + amoxicillin × 7–14 days) or quadruple therapy if local resistance high
Clarithromycin resistance increasing in GCC — sequential or bismuth-based quadruple therapy preferred in some centres
Confirm eradication with stool antigen test 4 weeks after completing antibiotics (not serology — IgG remains positive post-eradication)

NSAID Use in GCC

High prevalence of musculoskeletal disorders (construction workers, domestic workers) drives high OTC NSAID use
Cultural tendency to self-medicate with OTC diclofenac, ibuprofen, naproxen available without prescription in some GCC countries
Combination of NSAIDs + anticoagulants (for AF, DVT) dramatically increases GI bleed risk (× 10–15 relative risk)
Nursing action: thorough medication history — specifically ask about OTC pain medications, herbal remedies
PPI co-prescription mandatory if NSAIDs cannot be stopped (omeprazole 20mg OD or lansoprazole 30mg OD)

Liver Disease & Variceal Bleeding Trends

NAFLD-related cirrhosis increasing rapidly in GCC — high rates of obesity, type 2 diabetes, metabolic syndrome. NAFLD → NASH → cirrhosis → varices pathway taking 20–30 years.
Alcohol-related liver disease: Under-reported in GCC — non-Muslim expatriate workers (South Asian, Filipino, Western) may consume alcohol. Private history essential. Do not assume abstinence.
Hepatitis B and C endemic in some regions (Middle East, South Asia) — screen all cirrhotic patients
Schistosomiasis-related portal hypertension in expat workers from Egypt, Sudan, sub-Saharan Africa — consider in variceal patients from endemic countries

Traditional Remedy Misuse

High-dose ginger: Antiplatelet and anticoagulant properties — combined with aspirin/warfarin increases bleeding risk. Traditional use of ginger tea in large quantities.
Herbal teas / black seed (Nigella sativa): Widely used in GCC — generally safe at culinary doses but large therapeutic doses may affect coagulation
Turmeric: Antiplatelet effect at high doses (supplemental turmeric, not dietary)
Action: Always ask specifically about herbal supplements and traditional remedies. Many patients do not volunteer this information to healthcare providers.

🏥 GCC Endoscopy Capacity & Centres

Service Availability

24/7 emergency OGD: Available at all major tertiary centres in GCC — response time typically within 1–2h of referral
Out-of-hours endoscopy: On-call gastroenterology teams at academic hospitals. Community hospitals transfer to tertiary centre.
TIPS available at selected centres (requires IR + hepatology + vascular surgery capability)
Helium endoscopy (balloon enteroscopy for small bowel) available at specialist centres

Leading GI Bleeding Centres — GCC

Rashid Hospital, Dubai (UAE): Major trauma and emergency GI centre. 24/7 emergency endoscopy. Level 1 trauma centre with GI surgery.
SKMC (Sheikh Khalifa Medical City), Abu Dhabi: Tertiary gastroenterology and hepatology services. TIPS-capable.
HMC (Hamad Medical Corporation), Doha, Qatar: National GI bleed pathway. Dedicated interventional GI unit. Academic centre with research programme.
King Faisal Specialist Hospital, Riyadh / King Abdulaziz Medical City — Saudi Arabia tertiary centres

Language & Cultural Considerations for GCC Nurses

Patient population is highly diverse — Arabic, Urdu/Hindi, Tagalog, Bengali, Malayalam, Tamil, English
Use certified medical interpreters — not family members for consent discussions (especially serious diagnoses)
Cultural modesty: ensure same-sex nurse where possible for sensitive examinations (DRE, abdominal examination)
Ramadan: patients may have been fasting — adjust history accordingly (dehydration, missed medications)
Prayer time awareness: schedule non-urgent procedures around prayer times where clinically safe to do so

GI Bleeding — Comprehensive Nursing Guide