Upper GI Bleeding: Causes, Investigations & Clinical Considerations

Upper gastrointestinal (GI) bleeding is a high-priority emergency that presents as haematemesis (vomiting blood) or melaena (black, tarry stools). Severity ranges from minor mucosal bleeds to life-threatening haemorrhages, requiring urgent assessment and intervention.

Common Causes of Upper GI Bleeding

🔴 Peptic Ulcers – The leading cause, often due to Helicobacter pylori infection or NSAID-induced mucosal injury.
🔴 Oesophageal Varices – Occur in portal hypertension, usually secondary to cirrhosis, and can cause massive haemorrhage.
🔴 Mallory-Weiss Tears – Longitudinal mucosal lacerations at the gastro-oesophageal junction, triggered by forceful vomiting or retching, commonly seen in alcohol dependence and eating disorders.
🔴 Gastric or Oesophageal Cancer – Tumour-related bleeding due to mucosal erosion, vascular invasion, or ulceration.
🔴 Erosive Gastritis – From alcohol, stress, NSAIDs, or infection, causing diffuse capillary oozing rather than acute haemorrhage.
🔴 Dieulafoy Lesion – Rare but severe arterial abnormality, leading to intermittent massive GI haemorrhage, often in the stomach.

Investigating Upper GI Bleeding

🩺 Clinical Assessment
- History & Symptoms:
- Haematemesis (bright red vs. coffee-ground appearance)
- Melaena (suggests slower upper GI bleeding)
- Fatigue, pallor, hypotension (suggests significant blood loss)
- Recent NSAID use, anticoagulation, or liver disease history
- Physical Examination:
- Haemodynamic stability (HR, BP, signs of shock)
- Abdominal exam (epigastric tenderness → ulcer, hepatomegaly → portal hypertension)
- Signs of chronic liver disease (ascites, jaundice, spider naevi → varices likely)

📍 Key Investigations

✅ Upper GI endoscopy – Gold standard for diagnosing and treating bleeding sources. Can identify ulcers, varices, malignancies, and provide interventions like clip placement, adrenaline injection, or thermal coagulation.
✅ Faecal Occult Blood Test (FOBT) & H. pylori Testing – Used when bleeding is suspected but unclear; H. pylori stool antigen or urea breath test for ulcer-related bleeding.
✅ Blood Tests:
- FBC (check haemoglobin for anaemia)
- Iron studies (microcytic anaemia suggests chronic bleeding)
- Coagulation profile (INR/PT) (especially in patients on warfarin, DOACs)
- Liver function tests (LFTs) (suspect varices if cirrhotic features present)

🛑 When to Consider an Urgent Intervention?

🚨 Signs of haemodynamic compromise → Hypotension, tachycardia, confusion → Requires urgent resuscitation & endoscopy
🚨 Massive haematemesis or fresh blood per rectum → Consider arterial bleed or variceal rupture

First-Line Management Approach

🔹 Resuscitation FIRST – IV fluids ± packed RBC transfusions if unstable
🔹 Urgent endoscopy within 24 hours – Diagnostic & therapeutic
🔹 Proton Pump Inhibitors (PPIs) – High-dose IV if peptic ulcer bleeding suspected
🔹 medication for Variceal Bleeding – Reduces portal venous pressure
🔹 Balloon Tamponade (Sengstaken-Blakemore Tube) – Temporary measure for uncontrolled variceal haemorrhage

💡 Key Takeaway: Upper GI bleeding requires rapid risk stratification and early endoscopic intervention. Understanding risk factors, investigations, and management ensures you’re prepared for real-world clinical scenarios.