IM15.{9-10,16} | GI Bleeding Investigations — Summary & Reflection

KEY TAKEAWAYS

Investigation in GI bleeding follows a rational tiered hierarchy: first-line (universally applicable at cannula insertion): CBC (serial Hb, MCV, platelets), PT/INR/aPTT, U&E + BUN:creatinine ratio (>20:1 = upper source), LFTs, blood group and crossmatch, lactate. Second-line (diagnosis-directed): H. pylori (CLO test at OGD — note PPI false-negatives, confirm with stool antigen or UBT if negative on PPI); stool examination and occult blood (for chronic/occult bleeding evaluation). Third-line (source identification): OGD within 24 hours for UGIB (urgent ≤12h if Glasgow-Blatchford ≥6, haemodynamically stabilised); colonoscopy for significant LGIB after bowel prep; capsule endoscopy for obscure bleeding (negative OGD + colonoscopy); CT angiography (detects bleeding ≥0.3 mL/min) when endoscopy fails or is not feasible; mesenteric angiography + TAE when active arterial bleeding confirmed on CTA.

Forrest classification of peptic ulcer stigmata: Ia (spurting, ~55% rebleed — endoscopic haemostasis mandatory), IIa (visible vessel, ~43% — treat), IIb (clot, ~22% — consider), IIc/III (<10%/<5% — medical treatment). Indications for surgery: endoscopic failure (two attempts), transfusion >6 units/24h despite haemostasis, surgical emergency (aortoenteric fistula, perforation). TIPS = salvage for refractory variceal bleeding. Glasgow-Blatchford = pre-endoscopy triage; Rockall = post-endoscopy mortality/rebleed prediction — use in sequence, not interchangeably.

REFLECT

Consider the opening scenario — the junior doctor ordering 14 tests and an immediate endoscopy before resuscitation. Now that you have the investigation framework, what is the correct sequence for this patient? How would you explain to a colleague the difference between the Glasgow-Blatchford Score (which tells you whether to admit and scope) and the Rockall Score (which tells you what the prognosis is after you have scoped)? In a resource-limited setting in India where 24-hour endoscopy may not be available, which clinical decision would you make about a patient with Glasgow-Blatchford Score 8 and ongoing melaena but haemodynamic stability — and what would you communicate to the family about the investigation plan?