GI Bleed
A-to-E Assessments
SimulationUse this resource in conjunction with your real-world training
Experience Summary
In this experience, watch as a candidate undertakes a simulated A to E assessment of a patient presenting with haematemesis, and undergoes subsequent debrief.
Clinical Context
Upper gastrointestinal (GI) bleeding refers to haemorrhage originating proximal to the ligament of Treitz and encompasses presentations such as haematemesis, melaena, or both. Common causes include peptic ulcer disease, oesophageal varices, gastritis, and malignancy. It is a potentially life-threatening condition requiring rapid, structured management.
Assessment
A focused history should clarify the nature of bleeding (haematemesis vs. melaena), duration, and associated features such as dizziness or syncope. Risk factors include NSAID use, anticoagulants, alcohol excess, and known liver disease. Examination should assess hemodynamic stability and look for stigmata of chronic liver disease or abdominal pathology.
Initial investigations include full blood count, urea and electrolytes (often elevated urea in upper GI bleeding), liver function tests, coagulation profile, and group and crossmatch. Risk stratification tools such as the Glasgow-Blatchford Score help guide urgency of intervention and disposition.
Early Management
Two large-bore intravenous cannulas should be inserted for prompt fluid resuscitation with crystalloids and blood products if required. A restrictive transfusion strategy is generally recommended (e.g., transfuse if hemoglobin <70 g/L in stable patients). Coagulopathy should be corrected appropriately. Pharmacologic therapy is guided by suspected aetiology. Proton pump inhibitors are commonly administered empirically for suspected non-variceal bleeding. In suspected variceal haemorrhage, vasoactive agents (e.g., terlipressin) and prophylactic broad-spectrum antibiotics should be started promptly.
Definitive Management
Upper GI endoscopy within 24 hours (or sooner in unstable patients) is the cornerstone of diagnosis and treatment. Endoscopic therapies include injection, thermal coagulation, clipping, or band ligation for varices. If bleeding persists despite endoscopic measures, interventional radiology (embolisation) or surgery may be required.
Patients often require close monitoring in a high-dependency or intensive care setting. Long-term management focuses on treating underlying causes, such as Helicobacter pylori eradication or secondary prevention of variceal bleeding.
Learning Outcomes
- Observe a simulated A to E assessment of a patient with an upper GI bleed.
- Reflect on the candidates A to E assessment - what did you think went well? What didn’t?
- Understand the initial assessment and management of a patient with an upper GI bleed.
External Resources