Acute upper gastrointestinal [GI] bleeding is a common medical emergency with an estimated incidence of 134 per 100 000 population [Button et al, 2011]. It occurs above the ligament of Treitz, the boundary between the duodenum and the jejunum. National guidelines have been produced by the National Institute for Health and Care Excellence [NICE] [2012] and by a collaboration between the Scottish Intercollegiate Guidelines Network [SIGN] and the British Society of Gastroenterology [SIGN, 2008] to improve patient outcomes. However, the 2015 National Confidential Enquiry into Patient Outcome and Death [NCEPOD] [2015] review on patients with acute upper GI bleeding found variable practice and less than adequate standards of care. Consequently, NCEPOD proposed a set of criteria to standardise practice [NCEPOD, 2015: 97-98]. Despite these, it is noteworthy that guidance specific to nursing care is lacking, and yet it is essential that nurses caring for patients with acute GI bleeding are aware of the current standards to ensure optimal care.
Presentation
Acute upper GI bleeding is a medical emergency so early recognition is essential. It may present with haematemesis, coffee-ground vomiting, melaena or as an unexplained fall in haemoglobin levels [Siau et al, 2017]. It may also present as fresh rectal bleeding, particularly when accompanied by haemodynamic instability.
Assessment and resuscitation
The Resuscitation Council UK [2015] recommends that the ABCDE [Airway, Breathing, Circulation, Disability, Exposure] approach is taken for all critically ill or deteriorating patients. This approach provides a systematic structure for assessing patients with suspected acute upper GI bleeding.
Airway
The patient's airway could be compromised with large-volume vomiting. It may be necessary to place the patient in the recovery position to help protect the airway. Suction should be applied orally, as required, to remove excess blood and secretions. If the patient is unconscious, an oropharyngeal or nasopharyngeal airway should be inserted. When the patient is critically ill, the resuscitation/critical care team should be in attendance to intubate the trachea and provide ventilation.
Breathing
The patient's respiratory rate and oxygen saturations should be monitored and oxygen given if required; if the patient is vomiting, nasal cannulae may be used. Should breathing be compromised, it will be necessary to initiate basic life support and call the resuscitation team.
Circulation
The patient's blood pressure and pulse should be monitored to check for hypovolaemic shock. This will typically present as tachycardia and hypotension. There should be secure intravenous access with a minimum of two large-bore cannulas to allow rapid infusion of fluids and blood. Urine output monitoring may be indicated in haemorrhagic shock. Importantly, blood pressure and pulse should be regularly assessed.
Patients should have bloods taken for cross-matching, full blood count, urea and electrolytes, and clotting. Blood gas tests can provide a rapid estimate of haemoglobin levels. In the case of major haemorrhage, most hospitals have a massive transfusion protocol that can be triggered, with empirically prepared group O negative blood, platelets and fresh frozen plasma [FFP] [SIGN, 2008; Association of Anaesthetists of Great Britain and Ireland et al, 2010]. Patients with acute upper GI bleeding should be screened for coagulopathy [abnormality in blood clotting], which should be addressed before investigations or treatment such as endoscopy take place.
Clotting anomalies may be due to liver problems or other diseases, e.g. haemophilia. Patients with liver disease may be given vitamin K and FFP in order to replace missing clotting factors. Clotting anomalies may also be iatrogenic from antithrombotic therapy, e.g. aspirin, clopidogrel or warfarin. The INR should be less than 1.4 in the case of patients with acute upper GI bleeding [NICE, 2012]. INR reversal may require the use of prothrombin complex concentrate or FFP. In patients with high thrombotic risk, e.g. if they have a metal heart valve, deepvein thrombosis or pulmonary embolism, bridging cover with heparin may be required to prevent thrombotic complications. Nurses should also be aware of novel oral anticoagulants, e.g. apixaban, dabigatran, rivaroxaban or edoxaban. The reversal agent for dabigatran is idarucizumab [NICE, 2018].
Disability
The patient's level of consciousness should be regularly assessed using the Glasgow Coma Scale [GCS]. This is particularly relevant in patients with liver cirrhosis, who may develop hepatic encephalopathy triggered by a variceal bleed. Altered consciousness may lead to airway compromise. As hypoglycaemia is also a complication of cirrhosis, capillary blood glucose should be checked.
Exposure/examination
It is important to obtain a full medical and social history, if possible, as this may be relevant to GI bleeding, e.g. a past history of peptic ulcer disease, non-steroidal anti-inflammatory drug use, liver disease or alcoholism. The patient will need to be examined for signs of shock such as pallor and cool extremities. Signs of dehydration should be assessed, including dry mucosa, lack of skin elasticity and sunken eyes. It will also be necessary to note stigmata of liver disease, e.g. jaundice, spider naevi, gynaecomastia, ascites and liver flap. A medical assessment will also include an abdominal examination and a rectal examination. The patient's temperature should be checked because sepsis can lead to complications in patients with cirrhosis and ascites.
Investigationd
A diagnosis of acute upper GI bleeding is confirmed by upper GI endoscopy. This is a visual examination of the oesophagus, stomach and duodenum during which biopsies can be taken, if required, and therapeutic interventions to stop bleeding can be carried out.
Blatchford and Rockall scores
The Blatchford and Rockall scores [Tables 1 and 2] are validated scoring systems that can be used to triage for endoscopy [Rockall et al, 1996; Blatchford et al, 2000]. A pre-endoscopic assessment can be made using the first three categories in the Rockall score: age, shock and comorbidity. The entire Rockall score can be used to predict patient prognosis following endoscopy.
Table 1. Blatchford risk score
| ≥130 | ≥120 | 0 |
| 120–130 | 100–120 | 1 |
| 100–120 | – | 3 |
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