St Emlyn’s Lesson Plans

Upper gastrointestinal bleeding: decisions under pressure

Discuss resuscitation, anticoagulant reversal and definitive haemostasis when GI-bleeding treatment decisions are complicated.

Early-career Emergency Medicine / Higher Specialty Training · 60-minute session

For learners

Before: Allow about 18 minutes in total.

When we meet: We will discuss a patient with cirrhosis and ongoing bleeding, then compare the options for someone close to the local discharge threshold.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: A whiteboard to show the tasks being done together, and current pathways.

Run: 60-minute session plan · 30-minute option

Before the session

If you are attending this session, complete the core preparation below before you come. Allow about 18 minutes in total.

Core preparation

NICE CG141: Acute upper gastrointestinal bleeding · About 10 minutes

Read CG141’s resuscitation and variceal/non-variceal management recommendations. Identify the actions that need early specialist involvement.

https://www.nice.org.uk/guidance/cg141/chapter/Recommendations

HALT-IT trial: Lancet 2020 · About 5 minutes

Read the HALT-IT abstract, including the primary result and harms. Consider whether evidence for TXA in trauma answers the GI-bleeding question.

https://pubmed.ncbi.nlm.nih.gov/32563378/

Think about (allow 3 minutes): Which information would you need before discussing reversal of anticoagulation during a major GI bleed?

Picture the scene

A patient with melaena and coffee-ground vomiting is arriving. You need to organise resuscitation and definitive haemostasis while considering the risks of treatment.

By the end of the session

Justify a resuscitation and escalation plan using clinical response.
Distinguish early variceal and non-variceal management.
Explain a defensible plan for anticoagulation, endoscopy and low-risk follow-up.

After the session

Compare your local pre-endoscopy PPI and ambulatory policy with NICE and discuss any difference with gastroenterology.
Rehearse a major-haemorrhage referral including the definitive haemostasis plan.

Optional further learning

You do not need to complete this before attending. The listening time is additional to the core preparation above.

Optional listening · 18 min 29 sec

St Emlyn’s Podcast: Ep 290 - Shock with Rich Carden at Trauma 2030

Explore why a restored blood pressure may not mean restored tissue perfusion.

Listen to the episode

Search for this episode by title in MedPod Learn if you want to record your listening there.

Use this trauma discussion to explain how you would reassess perfusion and the duration of shock in GI bleeding. Identify which trauma interventions cannot simply be transferred. Use current GI-bleeding and major-haemorrhage guidance for management.

https://www.stemlynspodcast.org/e/ep-289-shock-with-rich-carden-at-trauma-2030/

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 18 minutes in total.

Before learners arrive

Invite an experienced facilitator familiar with GI bleeding and local reversal policy.
Bring the current major-haemorrhage, reversal and endoscopy pathways, including network rescue options.
Check the local ambulatory threshold before teaching.

Equipment: A whiteboard to show the tasks being done together, and current pathways.

Setup: Give pairs responsibility for resuscitation, reversal or definitive haemostasis in the first case, then bring their plans together. Discuss the stable case as a group, including the patient’s circumstances.

If the preparation has not been completed

Replace the first-hour opening and evidence appraisal (15 minutes). Use ten minutes to read the linked CG141 early-management sections and HALT-IT abstract together, then five minutes to identify actions that require early specialist help. Bring the local reversal and endoscopy pathways to the case discussion. For the 30-minute version, use the first seven minutes for a five-minute shared read and two-minute comparison, replacing competing risks and the HALT-IT conclusion.

Suggested session plan

0–5 min — The first hour. Ask what would make the next hour difficult.
5–15 min — Appraise one claim. Use HALT-IT to discuss why evidence from another bleeding condition may not transfer.
15–43 min — Work through two cases. Spend 18 minutes on the shock case and ten on the decision about discharge.
43–53 min — Defend a plan. Groups present decisions, uncertainty and what would trigger a change.
53–60 min — Consolidate and choose a follow-up action. Each participant identifies a local pathway inconsistency to resolve.

Start the discussion

Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.

Cases and discussion

Use these cases, or invite an anonymised case from the group that addresses the same questions.

Shock, liver disease and anticoagulation

A 62-year-old with cirrhosis and atrial fibrillation treated with apixaban has haematemesis, BP 82/48 and ongoing bleeding.

Add this information as the discussion develops:

Endoscopy is being mobilised. The team asks about reversal, transfusion, terlipressin and TXA.

Ask the group:

Which decisions can run in parallel and who should lead each?
What information makes reversal safer?
How will you avoid substituting medication for definitive haemostasis?

Discussion notes

Points to draw out:

Coordinate ED, gastroenterology, anaesthesia/critical care, blood bank and relevant haematology advice; stabilisation and definitive care proceed together.
Confirm agent, timing, renal function and severity; use the current local reversal pathway and product-specific guidance rather than a blanket instruction.
For suspected variceal bleeding, NICE recommends early terlipressin and prophylactic antibiotics; check contraindications, monitoring and the specialist plan.
TXA should not be routinely added for GI bleeding. Resuscitate to the individual rather than chasing a normal haemoglobin.

Common misconceptions:

Treating anticoagulant reversal as interchangeable between agents.
Routine blind balloon tamponade by an inexperienced team.

For a more experienced group: Ask what rescue options the local network offers if endoscopic control fails.

The almost-ambulatory patient

A stable patient has self-limited haematemesis after NSAID use. Their Glasgow-Blatchford score is one, and they live alone far from hospital.

Add this information as the discussion develops:

The local pathway accepts selected patients with this score; NICE’s early-discharge recommendation specifies zero.

Ask the group:

How will you reconcile guideline and local policy?
What does shared decision-making need to include?
What follow-up failure would make discharge unsafe?

Discussion notes

Points to draw out:

Explain the difference and use a locally approved pathway with senior review. Do not silently change the national threshold.
Consider ongoing symptoms, comorbidity, transport, access to help and the patient’s preferences.
Arrange accountable follow-up and return advice; a low intervention-risk score is not a guarantee of a safe home situation.

Common misconceptions:

Assuming an operational pathway removes individual responsibility.
Giving a PPI as a substitute for assessment or necessary endoscopy.

For a more experienced group: Discuss a patient taking antiplatelets after a recent coronary intervention with cardiology input.

Important clinical points

Use current product-specific reversal guidance with senior expertise for life-threatening bleeding.
Unstable patients need endoscopy immediately after resuscitation; other admitted GI-bleeding patients generally need it within 24 hours under NICE CG141.
Balloon tamponade and other rescue procedures require expert teams and an explicit airway/definitive-treatment plan.

Closing the session

Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.

Why should a trauma haemorrhage drug bundle not be copied wholesale?
What will you check before reversing a DOAC?
Why might two patients with similar low-risk scores need different plans for admission or discharge?

Key teaching points:

Plan definitive haemostasis while resuscitation continues.
Make any difference between national guidance and a locally approved pathway explicit.
Include treatment risks, support at home and access to follow-up when deciding whether discharge is appropriate.

Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.

Adapting the discussion

Uncertainty and local practice

International pre-endoscopy PPI recommendations and ambulatory thresholds vary. Teach the NICE position explicitly and record local departures for specialist review.

If the discussion drifts

Which decision will change outcome now, and who owns it?

For a more experienced group

Run a multidisciplinary tabletop exercise with an endoscopist, anaesthetist and blood-bank colleague; examine how failure of first-line haemostasis changes the pathway.

A 30-minute version

30 minutes: competing risks 3; HALT-IT conclusion 4; shock case 15; discharge discussion 5; reflection 3. Omit the full evidence appraisal.

Evidence and guidance

NICE CG141: Acute upper gastrointestinal bleeding — Risk assessment, resuscitation, endoscopy and variceal/non-variceal treatment.https://www.nice.org.uk/guidance/cg141/chapter/Recommendations
HALT-IT trial: Lancet 2020 — Primary randomised trial: no reduction in bleeding deaths; more venous thromboembolic events with the studied TXA regimen.https://pubmed.ncbi.nlm.nih.gov/32563378/