Should this UGI bleed go to ICU?

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KEY

🔍- Deep Dive

📌- Clinical Application

🔸 - Weak Evidence

🔹 - Strong Evidence

📑 - Evidence summaries

✅ - Recommended treatment

⚠️ - Critical Information

Vitals are normal. The patient looks fine.

And yet — you still admit.

Because: “It’s a GI bleed… anything can happen.”

We’ve all said it. But let’s be honest —is that actually a good reason?

Let’s break it down.

👉

Jump to what matters ⏬

What is Upper GI Bleed?

Upper gastrointestinal haemorrhage refers to bleeding originating proximal to the ligament of Treitz — typically from the esophagus, stomach, or duodenum.

The ligament of Treitz is the suspensory muscle of the duodenum that connects it to the diaphragm.

The most common causes include:

Peptic ulcer disease (PUD) — accounting for up to 67% of cases

Variceal bleeding — especially in patients with liver disease

Mallory–Weiss tears

Aorto-enteric fistula — rare but catastrophic, often presenting with massive, rapid bleeding

Why Do We Care?

One of the most common GI causes of hospitalization

Mortality ~ 10%

Hypotension (SBP <90 mmHg) → strongly associated with mortality

Hematemesis → worse outcomes than melena

Variceal Bleeds — A Different Beast

Even though variceal bleeds are relatively less common, they:

Are high-pressure systems

Have high rebleeding rates (up to 30%)

Carry significant mortality

These are high-risk from the start

The Diagnostic Challenge

Presentation is not always obvious.

Hematemesis (~50%) and melena (~70%) are easier to recognize

But patients may also present with:

Syncope
Dizziness
Isolated tachycardia

And to confuse things further: Brisk UGIB can present as hematochezia

The Real ED Challenge

The problem is not identifying UGIB.

The real challenge is: Risk stratification and disposition

Step 1: Is the Patient Hemodynamically Unstable?

This is the first and most important decision point.

✅

🔹BSG guidelines recommend that patients with acute UGIB and ongoing hemodynamic instability be referred for critical care review

If the patient is unstable, the decision is already made.

If NOT unstable → Ask the next question

Could this be a variceal bleed?

If yes:

🔸Strongly consider ICU (Baveno VII recommends intensive or intermediate care)

Let’s take a few moments to discuss the “ Resuscitation Principles”

Airway

Indications for prophylactic intubation (ESGE/ Baveno VII)

Severe haematemesis

Agitation

Inability to protect the airway.

Altered consciousness

Actively vomiting blood.

Patients unable to tolerate endoscopy under conscious sedation

Breathing

Supplemental oxygen should be administered to achieve target saturations.

Closely observe for aspiration

Circulation

Volume Replacement

🔹All major guidelines agree on one thing: Restore perfusion first with crytalloid bolus (ESGE / Baveno VII / BSG)

Blood Transfusion Strategy

🔹This is one of the most consistent recommendations across guidelines: Restrictive transfusion is preferred

Target Hb: 7–9 g/dL (ESGE) / 7–8 g/dL (Baveno VII)

Higher targets only if:

Ischemic heart disease or
Significant comorbidities

🔍

Overtransfusion can:

Increase portal pressure

Worsen bleeding (especially variceal)

Other considerations

Proton Pump Inhibitors (PPI)

Guidelines differ:

🔹 ESGE → suggests high-dose IV PPI before endoscopy

NICE → does not recommend routine pre-endoscopy PPI

Do not delay endoscopy for PPI infusion

Antiplatelets & Anticoagulants

Continue aspirin (secondary prevention) - If at all interuptted start with in 3-5 days

Hold warfarin / DOACs initially

P2Y12 inhibitors → case-by-case (especially with stents → discuss with cardiology)

Timing of Endoscopy

🔹 All patients → within 24 hours (ESGE)

Unstable → immediate after resuscitation (NICE)

Adjuncts and Early Interventions

Erythromycin (pre-endoscopy)

Single dose, 250 mg given 30 – 120 minutes prior to upper gastrointestinal [GI] endoscopy

Consistenly recommended across guidelines

Improves visualization
Reduces repeat endoscopy and transfusion
Recommended in severe/ongoing bleeding

NG Tube

Not routinely recommended (ESGE)

Additional considerations in suspected variceal bleed (Baveno VII)

These patients are automatically high-risk

Start early:

Vasoactive agents : Terlipressin / somatostatin / octreotide
Antibiotics : Ceftriaxone

Correcting Coagulation

FFP → Not recommended

It maynot correct coagulopathy and worsen volume overload worsening portal hypertension
Offer only if (NICE)

Fibrinogen level of <1 g/L
a prothrombin time (international normalised ratio) or activated partial thromboplastin time >1.5 times normal

Tranexamic acid / rFVIIa → not recommended
Platelets → only if actively bleeding and <50 × 10⁹/L (NICE Guidelines)

Why?

Reduce portal pressure

Prevent infection

INR/PT do not reflect true coagulation status

It is important to focus on reducing portal hypetension over correcting INR

Step 2: Is It Truly an Upper GI Bleed?

Diagnosis is not always straightforward, but there are few clues that can help

Clues in history -

Known liver disease

Any other symptoms of liver disease like ascitis and encephalopathy

NSAID use (↑ risk ~4x)

Alcohol use

Prior PUD or H. pylori

Recent vomiting (Mallory–Weiss)

Clues in examination

PR exam to confirm melena

⚠️

Be cautious of imitators:

Iron

Bismuth

Black foods

True melena is jet black, tarry and foul-smelling

📌

Remeber this nuance

UGIB → can present as hematochezia

LGIB → can present as melena

Helpful Adjunct

BUN:Creatinine >30 → suggests UGIB

Fecal Occult Blood Test (FOBT)

No role in acute ED decision-making

American Gastroenterological Association say that the the only indication for FOBT is in colorectal cancer screening.
It has poor sensitivity (~25%)

Intermittent GI bleed or very acute GI bleed that has not had sufficient time to travel through the GI tract may not produce positive FOBT and GI bleed cannot be ruled out based on just a negative result.

High false positives

🔍

Many things can cause false positive

Foods: Animal-derived heme, high eroxidase foods (e.g. broccoli, cauliflower, cantaloupe, carrots, squash), food dye additives (red, blue, yellow)

Medications: Activated charcoal, Pepto-Bismol, simethicone, N-acetylcysteine

Iatrogenic: Topical povidone-iodine solution (often used when inserting a Foley catheter)

Extra-intestinal sources: Epistaxis, hemoptysis (3)

📑

A retrospective cohort study found 3 predictors of UGI bleed 1

Melena

BUN:Cr >30

Age <50

Step 3: Risk Stratification

Common pre-endoscopy scores:

Glasgow Blatchford (GBS)

Rockall (Pre-endoscopy)

AIMS65

ABC (age, blood tests, co-morbidities) - Used to predict 30 day mortality.

Glassgow Blatchford Score

Risk Factor at Presentaion	Threshold	Score
BUN (mg/dL)	<18.2	0
ㅤ	18.2-22.3	+2
ㅤ	22.4-28	+3
ㅤ	28-70	+4
ㅤ	>70	+6
Hemoglobin (g/dL) for men	>13	0
ㅤ	12-13	+1
ㅤ	10-12	+3
ㅤ	<10	+6
Hemoglobin (g/dL) for women	>12	0
ㅤ	10-12	+1
ㅤ	<10	+6
Systolic blood pressure (mm Hg)	≥110	0
ㅤ	100–109	+1
ㅤ	90–99	+2
ㅤ	<90	+3
Pulse	≥100 (per min)	+1
Melena	Present	+1
Presentation	Syncope	+2
Co-morbidity	Liver disease history	+2
ㅤ	Cardiac failure present	+2

⚠️

GBS has the highest sensitivity for predicting intervention/death but no score reliably predicts rebleeding or mortality

Interpreting GBS

Low Risk : GBS 0–1 → consider discharge

Supported by: NICE / BSG / ESGE / ACG

✅

Inspite of this ESGE (2021) does mention that discharged patients should be informed of the risk of recurrent bleeding and be advised to maintain contact with the discharging hospital.

Moderate Risk : GBS ≥1 → Admit under appropriate speciality for endoscopy

BSG guidelines recommend admission under gastroenterology services.

High Risk : Hemodynamic instability or Suspected variceal bleed → Consider ICU

Scores support decisions , they do not replace clinical judgment. Always remeber no scoring system is foolproof. So if you have a patient with a score of 0 but they appear unwell don’t just discharge them just because of a score.

An additional marker: Lactate

📑

A retrospective cohort study showed elevated lactate = worse prognosis in GI bleed 6

Lactate >4 mmol/L → ~6.4× increased mortality

Each 1-point increase → ↑ mortality risk

🔍

What Matters

Before admitting a UGI bleed ask three simple questions:

1️⃣ Is the patient hemodynamically unstable?

👉 If yes

→ Initiate aggressive resuscitation with fluids and blood transfusion.

→ Admit to ICU ( BSG guidelines)

2️⃣ Is this truly an upper GI bleed?

Clues in history -

Known liver disease

Any other symptoms of liver disease like ascitis and encephalopathy

NSAID use (↑ risk ~4x)

Alcohol use

Prior PUD or H. pylori

Recent vomiting (Mallory–Weiss)

Clues in examination

PR exam to confirm melena

Helpful Adjunct

BUN:Creatinine >30 → suggests UGIB

👉 If yes → ask:

➡️ Could this be a variceal bleed?

👉 If yes → Admit to ICU / intermediate care (Baveno VII)

3️⃣ What is the Glasgow-Blatchford Score (GBS)?

Risk Factor at Presentaion	Threshold	Score
BUN (mg/dL)	<18.2	0
ㅤ	18.2-22.3	+2
ㅤ	22.4-28	+3
ㅤ	28-70	+4
ㅤ	>70	+6
Hemoglobin (g/dL) for men	>13	0
ㅤ	12-13	+1
ㅤ	10-12	+3
ㅤ	<10	+6
Hemoglobin (g/dL) for women	>12	0
ㅤ	10-12	+1
ㅤ	<10	+6
Systolic blood pressure (mm Hg)	≥110	0
ㅤ	100–109	+1
ㅤ	90–99	+2
ㅤ	<90	+3
Pulse	≥100 (per min)	+1
Melena	Present	+1
Presentation	Syncope	+2
Co-morbidity	Liver disease history	+2
ㅤ	Cardiac failure present	+2