A 51-year-old woman presents with progressive dysphagia and weight loss. She has a history of Barrett's esophagus on surveillance. Upper endoscopy shows a stricturing lesion. What is the most appropriate next step?

Multiple biopsies of the lesion

A 48-year-old man presents with acute severe epigastric pain radiating to his back. CT shows pancreatic necrosis involving >60% of the gland. What is the most appropriate management?

Conservative management with IV fluids

Upper GI bleeding for UKMLA AKT: High-Yield Medicine (Core Systems) Lessons

Quick Overview

Upper GI bleeding (UGIB) is defined as haemorrhage proximal to the ligament of Treitz. Annual incidence: 50-150/100,000, with 10-14% mortality. NICE NG158 emphasizes risk stratification (Glasgow-Blatchford Score pre-endoscopy, Rockall post-endoscopy), immediate resuscitation, and timing of endoscopy based on risk. Variceal vs non-variceal bleeding requires distinct management pathways.

Core Facts & Concepts

Risk Stratification Systems:

Score	Timing	Variables	Use
Glasgow-Blatchford (GBS)	Pre-endoscopy	Urea, Hb, BP, pulse, melaena, syncope, hepatic/cardiac disease	Score ≥1: needs intervention; Score 0: safe for outpatient
Rockall	Post-endoscopy	Age, shock, comorbidity, diagnosis, stigmata of bleeding	Predicts rebleeding/mortality

Key Numbers:

🩸 Transfusion threshold: Hb <70 g/L (restrictive strategy); consider <100 g/L if acute coronary syndrome
📊 GBS = 0: 0.5% risk of intervention/death; safe for discharge
⏱️ Endoscopy timing: <24h unstable patients; within 24h for all others (NICE NG158)
🚩 Massive bleed: >30% blood volume loss or ongoing haemodynamic instability

Figure 1: Endoscopy showing spurting arterial blood from gastric ulcer with visible vessel

Initial Management (NICE NG158):

ABC approach: 2× large-bore IV cannulae (16G)
Crystalloid resuscitation (target systolic BP >100 mmHg)
Tranexamic acid: Consider within 3h of bleeding onset
Cross-match 4-6 units; activate major haemorrhage protocol if needed
NBM status for endoscopy

Problem-Solving Approach

Immediate Assessment (First 15 minutes):

Haemodynamic stability: Pulse, BP, capillary refill, urine output
Calculate GBS: Determines admission vs discharge
Bloods: FBC, U&E (urea:creatinine ratio >100 suggests UGIB), coagulation, LFTs, group & save/cross-match
Stigmata of chronic liver disease: Spider naevi, ascites, jaundice → suspect varices
Drug history: NSAIDs, anticoagulants, antiplatelets, SSRIs

Figure 2: Endoscopy showing oesophageal varices with red whale markings

🚩 Red Flags for Immediate Endoscopy (<24h):

Haemodynamic instability despite resuscitation
GBS ≥12
Suspected variceal bleeding
Inpatient with active bleeding

Variceal vs Non-Variceal Pathway:

VARICEAL (suspect if chronic liver disease):

Terlipressin 2mg IV bolus, then 1-2mg/4-6h for 5 days
Prophylactic antibiotics: Ceftriaxone 1g IV daily (reduces infection/mortality by 20%)
Urgent endoscopy: variceal band ligation (first-line) or sclerotherapy
Sengstaken-Blakemore tube: temporary bridge if uncontrolled

NON-VARICEAL:

PPI therapy: High-dose IV (e.g., omeprazole 80mg bolus, then 8mg/h infusion) post-endoscopy for high-risk lesions
Endoscopic therapy: adrenaline injection + thermal coagulation/clips for Forrest Ia/Ib/IIa lesions

Analysis Framework

Forrest Classification (Peptic Ulcer Bleeding):

Grade	Description	Rebleed Risk	Endoscopic Treatment
Ia	Spurting arterial bleed	90%	Yes - dual therapy
Ib	Oozing bleeding	50%	Yes - dual therapy
IIa	Visible vessel	40%	Yes - dual therapy
IIb	Adherent clot	20%	Consider therapy
IIc	Haematin base	5%	No
III	Clean ulcer base	3%	No

Differential Diagnosis by Presentation:

Haematemesis (fresh blood): Oesophageal/gastric source, rapid bleeding
Coffee-ground vomit: Slower gastric bleeding, acid exposure
Melaena alone: Duodenal/small bowel (sticky, black, offensive stool)

Visual Aid

Transfusion Strategy (NICE NG158):

Clinical Context	Threshold	Target
Standard	Hb <70 g/L	70-90 g/L
ACS/significant CVD	Hb <100 g/L	100 g/L
Ongoing bleeding	Clinical judgment	Maintain perfusion

Key Points Summary

✓ GBS = 0: Safe for outpatient management; GBS ≥1 requires admission (NICE NG158)

✓ Transfusion: Restrictive strategy (Hb <70 g/L) reduces mortality vs liberal approach

✓ Variceal bleeding: Terlipressin + prophylactic antibiotics (ceftriaxone) + urgent endoscopy with banding

✓ High-dose PPI: Only indicated post-endoscopy for high-risk non-variceal lesions (Forrest Ia-IIa)

✓ Endoscopy timing: <24h if unstable/high-risk; within 24h for all admitted patients

✓ Dual endoscopic therapy: Adrenaline injection PLUS mechanical/thermal method for active bleeding/visible vessel

✓ Anticoagulant management: Reverse if life-threatening; balance thrombotic vs bleeding risk with haematology input

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