Upper gastrointestinal bleeding (UGIB): haematemesis and melaena
Overview
UGIB is bleeding originating proximal to the ligament of Treitz (duodenojejunal junction). Presentation ranges from occult melaena to massive haematemesis with hypovolaemic shock. In the UK it accounts for many admissions and carries a substantial mortality (~10%), most commonly from exsanguination or complications of comorbidity.
Early structured assessment, haemodynamic stabilisation, appropriate pharmacotherapy and timely endoscopic (or radiological/surgical) haemostasis are the pillars of management (NICE CG141).
Presenting features
- Haematemesis: fresh bright red blood or “coffee‑ground” vomitus.
- Melaena: black, tarry stools that may reflect slower or resolved UGIB.
- Haematochezia: bright rectal bleeding - usually lower GI but can occur with very brisk UGIB.
- Signs of hypovolaemia: tachycardia, hypotension, reduced consciousness, cold peripheries.
- Important history: liver disease or heavy alcohol use, prior peptic ulcer disease, NSAID/antiplatelet/anticoagulant use, prior varices or portal hypertension, prior endoscopic interventions.
Common causes (approximate frequencies)
Initial ED priorities
1. Use the ABCCE approach (Airway, Breathing, Circulation, Disability, Exposure). Protect the airway early if there is ongoing massive haematemesis, an altered GCS, or planned intubation for endoscopy. 2. Obtain vascular access: at least two large‑bore IV cannulae (16-18G). Seek early senior input. 3.
Immediate investigations: FBC (Hb, platelets), group & save/crossmatch, U&Es, LFTs (including albumin), coagulation (PT/INR, APTT), lactate and ABG if shocked. 4.