St Emlyn’s Lesson Plans

Upper gastrointestinal bleeding: first assessment

Work through initial care for upper GI bleeding and the assessment needed before considering discharge.

New to Emergency Medicine / Induction / Early-career Emergency Medicine · 45-minute session

For learners

Before: Allow about 16 minutes in total.

When we meet: We will discuss resuscitation of an unstable patient and the assessment and follow-up of someone who appears low risk.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: Observation chart, blank blood-request form and locally approved risk tool.

Run: 45-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 16 minutes in total.

Core preparation

NICE CG141: Acute upper gastrointestinal bleeding · About 10 minutes

Read CG141’s risk-assessment, resuscitation and endoscopy-timing recommendations. Note how the pathway differs for unstable and stable patients.

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

HALT-IT trial: Lancet 2020 · About 3 minutes

Read the HALT-IT abstract’s results and conclusion, including adverse events. Note what it means for routine TXA use in GI bleeding.

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

Think about (allow 3 minutes): What would make you escalate before waiting for a haemoglobin result?

Picture the scene

An ambulance pre-alert describes black tarry stools and coffee-ground vomiting. What do you need to know before the patient arrives?

By the end of the session

Recognise haemodynamic compromise and activate senior support.
Describe initial investigations, monitoring and referral for suspected upper GI bleeding.
Use pre-endoscopy risk assessment within an approved follow-up pathway.

After the session

Find the out-of-hours endoscopy contact before your next shift.
Check one discharge plan for an explicit follow-up owner.

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 16 minutes in total.

Before learners arrive

Locate the GI-bleed pathway, major-haemorrhage call and endoscopy contact.
Bring the local Glasgow-Blatchford tool and outpatient follow-up arrangements.

Equipment: Observation chart, blank blood-request form and locally approved risk tool.

Setup: As a group, prepare for the pre-alert by allocating the first tasks. Then work in pairs on the stable case, checking what is needed for the risk score and an achievable follow-up plan.

If the preparation has not been completed

Replace the pre-alert and resuscitation-space opening (12 minutes). Read the linked CG141 risk-assessment, resuscitation and endoscopy-timing sections for seven minutes, then spend five minutes assigning the first tasks for the unstable case. Use the local GI-bleed pathway supplied by the facilitator. For the 30-minute version, use the three-minute pre-alert slot for a focused read of the CG141 resuscitation recommendations; return to the guidance during the unstable case.

Suggested session plan

0–5 min — Plan for arrival. Ask for the three most useful pre-alert questions.
5–12 min — Prepare the resuscitation space. Group assigns people, monitoring and first requests.
12–34 min — Discuss both cases. Contrast action during shock with thoughtful risk assessment when stable.
34–40 min — Agree referral and follow-up. Practise communicating urgency and follow-up ownership.
40–45 min — Choose a follow-up action. Identify one practical preparation for the next GI bleed.

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.

Ongoing bleeding and shock

A 45-year-old with melaena has BP 78/44, marked weakness and a history of liver disease. Haemoglobin is 61 g/L.

Add this information as the discussion develops:

They become more drowsy and have another episode of vomiting blood.

Ask the group:

What needs to happen in the first minutes?
Who must be involved now?
Which findings will you reassess while definitive treatment is organised?

Discussion notes

Points to draw out:

Use a monitored resuscitation area, ABCDE assessment, urgent senior help and early endoscopy/critical-care involvement.
Obtain suitable IV access, blood tests and blood-bank samples; activate the local major-haemorrhage pathway when indicated.
Base resuscitation on the whole clinical picture, ongoing loss and response. A fixed haemoglobin threshold is not a waiting rule during major haemorrhage.
Anticipate airway risk and deterioration; urgent endoscopy follows resuscitation.

Common misconceptions:

Waiting for a repeat haemoglobin before escalating.
Treating coffee-ground vomiting as proof that bleeding has stopped.

For a more experienced group: Identify how the major-haemorrhage call reaches the endoscopy team out of hours.

Stable enough for a risk assessment

A 28-year-old has coffee-ground vomiting after two weeks of ibuprofen. They are currently well perfused and observations are normal.

Add this information as the discussion develops:

They ask to go home before blood results return.

Ask the group:

What information is needed for a Glasgow-Blatchford score?
What else matters beyond the score?
Who arranges follow-up if discharge is appropriate?

Discussion notes

Points to draw out:

Complete clinical assessment and the pre-endoscopy Glasgow-Blatchford score; do not guess missing values.
NICE supports considering early discharge at a score of zero, with a suitable agreed pathway; other local thresholds require explicit governance.
Review medicines, comorbidity, ongoing bleeding, support and ability to return. Give a named follow-up plan rather than an undefined GP handoff.

Common misconceptions:

Using a low score as permission to ignore persistent symptoms.
Calling someone low risk before required observations and tests are known.

For a more experienced group: Compare the local ambulatory eligibility threshold with the NICE recommendation.

Important clinical points

Do not routinely give TXA for GI bleeding; HALT-IT is complete and did not show benefit on bleeding deaths.
NICE advises against routine acid suppression before endoscopy for suspected non-variceal bleeding.
Suspected variceal bleeding changes early medication and antibiotic decisions; obtain senior support and use the GI-bleed pathway.

Closing the session

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

Why is a haemoglobin threshold insufficient in shock?
What distinguishes a risk score from a discharge plan?
Who needs to hear the referral first if bleeding continues?

Key teaching points:

Treat haemodynamic compromise promptly rather than waiting for a risk score or repeat blood result.
Arrange senior help and definitive haemostasis early.
A low-risk score needs to be considered alongside symptoms, circumstances and a reliable follow-up plan.

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

Transfusion, anticoagulant reversal and airway decisions are individualised senior decisions using current local protocols.

If the discussion drifts

What is the immediate threat, and what definitive care are we arranging?

For a more experienced group

Use the separate advanced GI-bleeding lesson for variceal treatment, reversal and competing transfusion risks.

A 30-minute version

30 minutes: pre-alert 3; unstable case 14; stable case 8; consolidation and reflection 5. Omit the detailed referral rehearsal.

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/