Bleeding from the upper gut

Understanding bleeding from the upper gut

What the signs mean

Two presentations signal upper gastrointestinal bleeding, and both need emergency care.

Haematemesis is vomiting blood. It may be fresh and red, indicating brisk bleeding, or dark and granular like coffee grounds, which is blood altered by stomach acid.

Melaena is a black, tarry, offensively smelling stool. The colour comes from blood that has been digested during its passage through the gut, and it indicates bleeding from the oesophagus, stomach or duodenum. It is quite distinct from the dark stool caused by iron tablets, which is not tarry and lacks the smell.

Understanding bleeding from the upper gut

What causes it

Several conditions bleed from the upper gut, and the commonest are treatable at endoscopy:

• Peptic ulcers, the single most frequent cause, often related to H. pylori or anti-inflammatory painkillers
• Oesophageal varices, enlarged veins that develop in liver disease and can bleed torrentially
• Severe gastritis or oesophagitis
• A Mallory-Weiss tear, a split at the junction of oesophagus and stomach caused by forceful vomiting
• Stomach or oesophageal cancer
• Angiodysplasia, fragile abnormal vessels

Understanding bleeding from the upper gut

What to do immediately

Go to a hospital emergency department. Do not drive yourself. Do not eat or drink anything, since an endoscopy will likely be needed and a stomach full of food makes it harder and less safe.

Take a list of your medications with you, particularly blood thinners and anti-inflammatory painkillers, as these directly affect both the cause and the treatment.

If you have known liver disease, say so on arrival, because bleeding varices are managed differently and more urgently.

Understanding bleeding from the upper gut

How it is treated

Initial treatment is resuscitation: fluids into a vein, blood tests, and a transfusion where needed to stabilise the patient. Acid-suppressing medication is started intravenously.

Endoscopy is then both the diagnostic and the therapeutic step, usually within twenty-four hours and sooner if bleeding is severe. Through the scope we can inject a bleeding ulcer, apply clips to close the vessel, use heat to seal it, or band bleeding varices. In most cases the bleeding is controlled endoscopically without any surgery.

Afterwards, treatment addresses the cause: clearing H. pylori, stopping the responsible painkiller, or managing the underlying liver disease to reduce the risk of further variceal bleeding.

Understanding bleeding from the upper gut

Preventing a recurrence

Once the bleeding is controlled, prevention matters as much as the emergency treatment did:

• Confirm H. pylori has been eradicated, with a follow-up test
• Stop anti-inflammatory painkillers, or use gastric protection where they are unavoidable
• Continue acid-suppressing medication for the prescribed course
• For varices, attend the planned banding programme rather than waiting for another bleed
• Avoid alcohol, particularly with liver disease