Clinical Assessment

There are many signs and symptoms which may identify a patient having a GI bleed. Identifying the presence of upper GI bleed can range from relatively easy to more challenging. In some instances where haematemesis (present in 50%) or melaena (present in 70%) exists the diagnosis is easier. It can be more difficult to identify in those patients who present with syncope (or presyncope), dizziness, or haematochezia, and some patients may be asymptomatic with the only clue being tachycardia or hypotension.

A high index of suspicion is required for these symptoms.

Hypotension (systolic blood pressure < 90mmHg) is associated with an increased risk of mortality (odds ratio 9.8). [3]

Patients presenting with haematemesis have a higher mortality compared with patients presenting with melaena alone. [4]

Points to look for in the history

• Known or suspected liver disease
• Profuse recent vomiting (suggests Mallory-Weiss tear)
• Previous peptic ulcer disease or gastritis
• Known or previous Helicobacter pylori infection
• Alcohol (not a direct pointer to variceal bleeding peptic ulcer disease bleeding is still more common within this cohort)
• Medication, particularly NSAIDs which increase the risk of UGIB four-fold. [5]

Learning Bite

Do a PR early as it may confirm fresh melaena.