Table 124 Causes of upper GI bleeding and relative frequency

• Oesophageal cause - oesophagitis, varices, Mallory-Weiss (19%)

• Rare causes - vascular malformation, Dieulafoy lesion, haemobilia, aorto-duodenal fistula (6%)

bleeds are due to peptic ulcers, with a variety of other causes listed in Table 12.4.

The majority of patients present with overt bleeding in the form of haematemesis and/or melaena, or more rarely with fresh bleeding per rectum. Haematemesis may produce fresh blood, as commonly seen with varices, or altered blood (coffee grounds) from a slowly bleeding ulcer. Melaena occurs when blood is partially digested during passage through the GI tract, resulting in a black, liquid stool with an unmistakable, foul smell. The passage of fresh blood per rectum from an upper GI source is a very worrying feature, as it implies a significant bleed causing rapid transit through the gut without time for melaena to form.

Some patients present with covert bleeding and are investigated for collapse or anaemia. In time it becomes obvious that they are bleeding, either by the appearance of overt bleeding, or as a result of endoscopic investigation.

The initial management of patients with bleeding is resuscitation appropriate to the severity of their condition. Most patients have a minor episode of bleeding and are never haemodynamically compromised by it, but others lose a lot of blood, relatively quickly and require prompt resuscitation. Patients who have lost a lot of blood will be tachycardic initially, and hypotensive as blood loss increases. Tachypnoea develops as oxygen delivery decreases, and at the same time conscious level is affected leading to restlessness, irritability, drowsiness, and even unconsciousness. Oxygen supplementation is often required, and intravenous fluid replacement must start immediately in patients who are compromised. It is important to remember that many patients take p-blockers regularly, so will not show a tachycardia, and that younger people can maintain their blood pressure well with significant blood loss so tachycardia is an important sign. Whether the intravenous fluid used is crystalloid or colloid is less important than the amount given, and it is important to have good venous access (two large bore cannulas). If a lot of blood has been lost the best resuscitation fluid is blood, even O-negative if there is no time for a cross-match. A clotting screen must always be performed on patients with bleeding, and those who require active resuscitation benefit from central venous pressure monitoring, and urethral catheterisa-tion with hourly urine output measurement.

Table 12.5. Rockall scoring system for upper GI bleeding.

Age (in years)

<60

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