1)  Immediately

2)  Assess severity of blood loss

Clinical pointers to significant blood loss

3)  Complete a Glasgow Blatchford Score and an UGIB bundle check list

The GBS is a well validated pre endoscopy risk assessment. 

Patients with GBS of 0 or 1 can be discharged and an outpatient endoscopy requested.

4)  Arrange Appropriate Monitoring

• Ward 5 or ITU / HDU for high risk bleeders.
• Monitor pulse, Bp and urine output hourly in high risk bleeders.
• Central line if significant cardio-respiratory co-morbidity.
• ITU outreach to be informed immediately about all high risk bleeders.
• Identify and respond to rebleeding episodes promptly – consider major haemorrhage protocol.

5)  Pre Endoscopy Treatment

• Complete the UGIB bundle.
• Blood Transfusion if shocked or Hb <70g/l.  Avoid over transfusion especially in cirrhosis (target Hb 70-100g/l).  If shocked activate major haemorrhage protocol (4 units of blood and 2 units FFP stat with urgent haematology advice).
• Confirm response to resuscitation.
• Surgical registrar to be informed about all high risk bleeders (before midnight bleep surgical registrar; between midnight and 8:00am arrange for patient to be seen on morning surgical ward round).  
• Patient nil by mouth until timing of endoscopy decided.
• Contact Endoscopy Department ASAP on Ext 26440 for high risk bleeders.  Complete endoscopy request form and hand in to endoscopy reception.  Aim for next day endoscopy.
• Oral PPI if acid suppression required.

Post Endoscopy Treatment

• IV PPI only indicated after endoscopic adrenaline injection therapy (Omeprazole 80mg bolus followed by 8mg/hr for 72 hrs, see PPI infusion chart).
• After endoscopic adrenaline injection therapy bleeders should be nursed in ITU or ward 5.
• Consider surgery for:    
  • Uncontrolled bleeding
  • Rebleeding episode
  • Transfusion > 4 units in 24 hours or > 8 units in 48 hours
• Check H. pylori antibody status in patients with peptic ulcer disease.  Hp eradication and 6 week stool antigen test to confirm eradication.

Bleeding oesophageal varices

• Prognosis related to severity of liver disease rather than magnitude of bleed.
• IV bolus terlipressin 2mg 6 hourly.
• Ceftriaxone 1g daily (high risk of SBP) if no evidence of infection treat for 3 days.  If Penicillin allergic treat with Teicoplanin 400mg 12 hourly for 3 doses then 24hrly along with Gentamicin  (give first dose as per Gentamicin calculator and then discuss further dosing with microbiology).
• Urgent OGD to confirm site of bleeding.
• Transfer to GI team (RIE) if
  • Significant GI bleeding in patient with liver failure or known varices and BGH gastroenterologist not available.
  • Variceal rebleed after banding.
• Sengstaken tube available in Endoscopy, Ward 5, Theatre and ED (easy to follow instructions).
• Patients transferred to RIE with a Sengstaken tube must be intubated for airway protection.

6)  Out of Hours Endoscopy

• It is appropriate for the majority of high risk bleeders to be examined on the next scheduled endoscopy list.  Failing resuscitation or rebleeding are the usual indications for out of hours endoscopy.
• A BGH gastroenterologist may be available on call.  At other times therapeutic endoscopy will be available at the Royal Infirmary of Edinburgh for patients that are unstable as a result of severe bleeding or have suspected acute variceal bleeding in a patient with known chronic liver disease.

The full agreement on RIE out of hours endoscopy support is shown here.