St Emlyn’s Lesson Plans
Initial assessment of upper gastrointestinal bleeding
Contrast a shocked patient with a stable low-risk presentation to practise resuscitation, escalation and reliable follow-up.
Medical Students · 45-minute session
For learners
Before: Allow about 12 minutes in total.
When we meet: We will compare resuscitation of an unstable patient with assessment and follow-up of someone whose Blatchford score is zero.
For facilitators
Send: the learner preparation link before teaching.
Bring: The case observations and blood results on screen or paper, the local risk tool and a handover sheet.
Before the session
If you are attending this session, complete the core preparation below before you come. Allow about 12 minutes in total.
Core preparation
NICE CG141 upper GI bleeding · About 8 minutes
Read “Risk assessment” (1.1), “Timing of endoscopy” (1.3), and the opening resuscitation recommendations 1.2.1–1.2.2. Focus on what must happen before endoscopy and how a risk score contributes to disposition.
https://www.nice.org.uk/guidance/cg141/chapter/Recommendations
HALT-IT trial · About 2 minutes
Read only the abstract’s findings and interpretation. Focus on bleeding-related death and the reported harms of tranexamic acid.
https://pubmed.ncbi.nlm.nih.gov/32563378/
Think about (allow 2 minutes): What must happen before calculating a risk score in a patient with haematemesis and shock?
Picture the scene
A person reports black tarry stools and coffee-ground vomiting. Before calculating a score, you need to know how they are now.
By the end of the session
- Recognise physiological compromise and call for senior resuscitation support.
- Explain the roles and limits of pre-endoscopy risk assessment.
- Describe the different early concerns in suspected variceal and non-variceal bleeding.
After the session
- Find the local endoscopy referral process and ask how the ED confirms that a low-risk referral has been received.
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 12 minutes in total.
Before learners arrive
- Locate the major-haemorrhage activation process, blood bank and out-of-hours endoscopy contact.
- Bring the local Blatchford tool and discharge pathway. Check the fictional dataset in case 2 before teaching, then let the group calculate the score before revealing the follow-up problem.
Equipment: The case observations and blood results on screen or paper, the local risk tool and a handover sheet.
Setup: Pairs prioritise the first three actions, then compare the unstable and stable pathways.
If the preparation has not been completed
Use five minutes in place of “Establish the essentials”. Display the observations from case 1 and the NICE resuscitation and endoscopy recommendations. Give pairs two minutes to name three immediate priorities, two to explain why a score must not delay care, and one to identify the local major-haemorrhage and endoscopy contacts supplied by the facilitator.
Suggested session plan
- 0–5 min — Explore. Ask what black stools plus collapse would change.
- 5–10 min — Establish the essentials. Locate immediate resuscitation and score sections.
- 10–32 min — Discuss & Apply. Spend 13 minutes on shock and 9 on low-risk follow-up.
- 32–40 min — Consolidate. Ask pairs to prioritise the first actions in shock, then describe the follow-up and return advice required for a low-risk discharge.
- 40–45 min — Reflect & Transfer. Ask learners to find how a low-risk endoscopy referral is sent and how the ED confirms it has been received.
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.
Dark stools with shock
A 45-year-old has melaena, BP 78/44, haemoglobin 61 g/L and lactate 7.1 mmol/L. There is a history of significant liver disease.
Add this information as the discussion develops:
- The patient vomits fresh blood and becomes more drowsy.
- The team asks whether to wait for a repeat haemoglobin before activating the major-haemorrhage pathway.
Ask the group:
- What needs to happen before completing the history?
- Who should be involved in airway, resuscitation and definitive haemostasis?
- Why is a fixed transfusion threshold inadequate in active major bleeding?
Discussion notes
Points to draw out:
- Move to an appropriate monitored resuscitation setting, call senior help, obtain suitable access and blood-bank samples, and activate the local major-haemorrhage process when indicated.
- Manage transfusion according to the whole clinical picture and bleeding severity. A laboratory number is not a reason to delay treatment of shock.
- Arrange urgent endoscopy after initial resuscitation for unstable severe bleeding; involve endoscopy and critical-care teams early.
- Suspected variceal bleeding needs specific senior-led treatment, including vasoactive therapy and antibiotics according to guidance and local policy.
Common misconceptions:
- Using a restrictive stable-patient haemoglobin threshold as the sole trigger in shock.
- Assuming liver disease proves a variceal source.
- Letting a score delay action.
For a more experienced group: Ask how anticoagulants change the consultation with haematology and why reversal must be drug-specific.
Coffee-ground vomit in a stable patient
A 28-year-old reports coffee-ground vomiting after several days of ibuprofen. Observations are stable and there is no ongoing visible bleeding.
Add this information as the discussion develops:
- For this fictional exercise: BP 125/78 mmHg, pulse 80/min, urea 4.5 mmol/L and haemoglobin 145 g/L. There has been no melaena or syncope, and there is no liver disease or heart failure. Calculate the Glasgow Blatchford score using the local tool.
- The score is 0, but there is no arranged endoscopy follow-up and the patient does not understand when to return.
Ask the group:
- What does low risk mean, and what does it not mean?
- Who owns the follow-up arrangement?
- What needs to be explained before a discharge decision?
Discussion notes
Points to draw out:
- The supplied values give a Glasgow Blatchford score of 0: none of the physiological, blood-test or history inputs scores a point. Check the inputs with the group before discussing discharge.
- NICE advises Blatchford scoring at initial assessment and consideration of early discharge at 0; apply the locally governed pathway with senior review.
- A score does not replace assessment of comorbidity, continuing bleeding, social circumstances or diagnostic uncertainty.
- Explain medication issues, recurrence of bleeding, collapse and how to obtain help; arrange the relevant secondary-care follow-up rather than transferring responsibility vaguely.
Common misconceptions:
- Calling coffee-ground material automatically benign.
- Treating a low score as a completed discharge plan.
For a more experienced group: Discuss why some local/specialty pathways use a different low-risk threshold and why students should use the adopted pathway rather than mix scores.
Important clinical points
- Do not use routine tranexamic acid for GI bleeding based on trauma practice; HALT-IT showed no bleeding-mortality benefit and increased venous thromboembolic events.
- Interpret haemoglobin alongside continuing bleeding, perfusion and the response to resuscitation.
- NICE does not recommend acid suppression before endoscopy for suspected non-variceal bleeding; distinguish post-endoscopic indications.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- Explain why resuscitation precedes scoring in case 1.
- State what a Blatchford 0 can and cannot establish.
- Name the team that owns outpatient follow-up locally.
Key teaching points:
- Coordinate resuscitation and definitive haemostasis early in severe bleeding.
- Use the risk score after assessing the patient’s immediate condition.
- A low-risk discharge needs agreed follow-up and clear return advice.
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
Source of bleeding is not established by appearance alone. Local transfusion and reversal decisions may depend on comorbidity and bleeding trajectory.
If the discussion drifts
Is this person stable enough for the step we are discussing?
For a more experienced group
Discuss which teams become involved when endoscopy fails to control the bleeding.
A 30-minute version
30 minutes: opening 3, essentials 5, shock 12, stable case 5, consolidation 3, reflection 2.
Evidence and guidance
- NICE CG141 — Resuscitation, Blatchford score, endoscopy and drug principles.https://www.nice.org.uk/guidance/cg141/chapter/Recommendations
- HALT-IT collaborators 2020 — Primary randomised trial replacing ‘trial in progress’.https://pubmed.ncbi.nlm.nih.gov/32563378/
Suggested curriculum links
GMC Outcomes for graduates / MLA 2026: Gastrointestinal bleeding; shock and risk assessment
Students practise escalation and risk-aware onward care.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
First published 2020-09-22 · Dan Waddington.