This document provides guidance on evaluating and managing a patient presenting with upper gastrointestinal bleeding. It outlines the differences between upper and lower GI bleeding and describes the relevant history, examination findings, and Rockall score for risk stratification. Key points include distinguishing symptoms of hematemesis versus hematochezia, assessing blood loss based on vital signs and volume, examining for stigmata of liver disease, and endoscopy to determine the source of bleeding and prognosis.

1. CLINICAL APPROACH TO PATIENT WITH
UPPER GASTROINTESTINAL BLEEDING

2. Features Upper GI bleed Lower GI bleed
Site Above Ligament Below Ligament
of Treitz of Treitz
Presentation Hemetemesis or Hematochezia
Malena
Nasogastric Blood Clear fluid
aspiration
Bowel sounds Hyperactive Normal
BUN/ Creatinine Increased Normal
ratio

3. HISTORY

4. Presenting Complaints
 Hematemesis
 Malena
 Hematochezia
 Symptoms of blood loss- lightheadedness, syncope,
dysnea
(Occult blood in stools)

5. MODE OF ENQUIRY
Onset ,episodes
True or spurious
Bleeding from oral cavity/nasopharynx
H/O retching with non bloody vomitus followed
by hemetemesis
H/O anorexia,dysphagia, rapid weight loss

6. H/O malena
H/O drug intake NSAIDs, aspirin or anti
coagulants
H/O alcohol intake
Any skin telangiectasias?
Any pigmentation?
Perioral
Diffuse

7. PAST HISTORY
 H/O Chronic Liver Disease
 H/O Peptic ulcer
 H/O Bleeding disorders
 Comorbidities -Pre existing CVS/Renal/CNS d/s
may be worsened by a/c bleeding
 H/O medical illness/surgical intervention
FAMILY HISTORY -hemetemesis

8. CLINICAL EXAMINATION

9. General Examination
Built and Nourishment
Pallor(chronic bleeding)
Icterus(CLD)
Cyanosis
Clubbing
Lymphadenopathy(CA stomach)
Edema

10. Vitals
Pulse
BP
HEMODYNAMIC INSTABILITY-Hypotension,
Tachycardia, Postural changes in BP and heart
rate
Respiratory Rate
Temperature

11. Assessment of Blood Loss
BLOOD LOSS CLINICAL FEATURES
500ml No systemic signs except in
elderly and anaemic patients
1000ml Tachycardia, Orthostatic
(20% reduction in blood volume) hypotension, syncope, light
headedness, nausea, sweating,
thirst
2000ml Profound shock and possibly death
(40% reduction in blood volume)

12. Also Look For
Any source of bleeding from oral cavity
Telengiectasias in skin, conjunctiva,oral cavity
Perioral/diffuse pigmentation
Paraneoplastic syndromes
STIGMATA OF CLD

13. Perioral pigmentation

14. Skin telengiectasias

15. Telengiectasia in Eye

16. STIGMATA OF CLD

17. Skin, nails and Hands
 Spider naevi - small telangiectatic superficial blood
vessels with a central feeding vessel
 Clubbing
 Leukonychia - expansion of the paler half-moon at the base
of the nail
 Palmar erythema - seen on the thenar and hypothenar
eminences, often with a blotchy appearance
 Bruising
 Dupuytren's contracture - can occur in the absence of liver
disease
 Scratch marks - particularly in cholestatic liver disease
 Flapping Tremor

18. Endocrine - due to excess oestrogens
Gynaecomastia
Testicular atrophy
Loss of axillary and pubic hair
Telengiectasias
Others
Hepatic fetor - characteristic sweet-smelling breath
Parotid swelling - particularly in alcohol-related liver
disease

19. Dupuytren’s contracture Spider naevi

21. Examination of Abdomen
Any mass lesion
Hepatosplenomegaly
Hyperactive bowel sounds
Examination of Lymph nodes

22. Rockall Score for Risk
Stratification in A/C
Upper GI Bleeds
Predicts Severity
Final score 0-11
Score<3 good prognosis
Score>6 indication for Surgery
Score>8 high risk of mortality

23. SCORE 0 1 2 3
1.Age <60 60-79 >80
2.Shock No shock Pulse>100 SBP<100
3.Comorbidity No Major CCF, IHD, Renal/Liver Metastatic
Major Failure cancer
4.Diagnosis Mallory All other GI malignancy
after Weiss tear or diagnosis
Endoscopy normal
5.Endoscopic None Blood in Adherent clot,
Evidence of Stomach Visible or
Bleeding spurting vessel

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