ED management of acute upper GI bleeding pathway

NHS Tayside ED Guidance
NHS Tayside

This pathway is for all patients presenting with a history of fresh blood haematemesis or melaena. This does not include food vomit with streaks of blood. All GI bleeding patients including those with a history of dark coloured or “coffee ground” vomit must be discussed with a senior before admission/discharge.

ED management of acute upper GI bleeding pathway form

Stable and not witnessed large volume haematemesis

Actions

  • Can be managed in stream 2
  • Large bore IV access
  • Bloods: FBC, U & E
  • Risk assessment using Blatchford score
  • Blatchford score 0 or 1; Bloods NAD, no malaena, go to exclusion criteria
  • Blatchford score greater than 1; exclusion criteria not met or other reason; admit AMU

Glasgow Blatchford score

Shocked and witnessed large volume haematemesis

Actions

  • Manage in resuscitation room
  • Seek Senior clinician support
  • Large bore access x2
  • FBC/U&E/Coag; Cross match 6 units or initiate massive haemorrhage protocol as appropriate
  • Discuss with Med Registrar to organise timely endoscopy etc.
  • If actively bleeding and platelet count  lower than 50 consider platelet transfusion
  • If actively bleeding and INR or APPT or PT greater than 1.5 times normal; consider FFP
  • If actively bleeding and on warfarin: prothrombin complex concentrate

If ulcer inflammation with witnessed significant GI bleed - give loading dose IV esomeprazole 80mg

If variceal bleeding 

  • give antibiotics
  • give terlipressin

Low risk UGIB for OP management

Blatchford score 0/1, bloods NAD, no melaena, no exclusion criteria

  • Request Outpatient OGD via paper request and deliver to Endoscopy unit FAO Michelle Fraser and "ED Urgent OP Bleed”.
  • Provide Outpatient OGD advice sheet via intranet
  • Stop NSAIDs
  • Give safety netting advice “if further bleeding, malaena or syncope then return to ED”
  • Write “OPD endoscopy” on the follow up section on the back of ED notes

 

Admission

Do not wait for blood results if patient’s destination is available and safe transfer. UGIB patients are usually for medical team but if signs of peritonism then surgical Team.

Exclusion criteria for Outpatient Management

  • Other reason for admission
  • On Warfarin
  • History of varices
  • Age over 70 years
  • Lives alone
  • No telephone

Editorial Information

Last reviewed: 01/03/2018

Author(s): R. Duncan, M. Groome, E. Kenyon.