Select an option to reveal the explanation.
Explanation of Answer
Best answer and reason
Correct answer: Additional endoscopic therapy with mechanical or thermal modality
Adrenaline injection alone is inadequate for high-risk stigmata (Forrest Ia-IIb) - the effect is transient and rebleeding rate is high. NICE CG141 and BSG recommend combination endoscopic therapy: adrenaline plus a mechanical (endoclips) or thermal (heater probe/bipolar coagulation) modality. If mechanical or thermal has not been added, further endoscopic treatment should be given during the same procedure or immediately.
Why the other options are wrong
Discharge the patient after 24 hours observation
Discharge without further therapy is inappropriate.
Interventional radiology as first-line
Ir is a rescue option after failed endoscopy.
No further therapy is required
Further therapy required.
Repeat adrenaline injection in 24 hours
Repeat adrenaline alone remains inadequate.
Exam takeaway
- Adrenaline alone is inadequate. Always add mechanical or thermal to complete haemostasis.
Learn the Condition
UGIB
UGIB
Background
UGIB is bleeding from a source proximal to the ligament of Treitz. Common medical emergency - annual UK incidence around 100 per 100,000. Mortality around 8-10 percent overall, higher in older and comorbid patients.
Aetiology
Peptic ulcer disease (duodenal more than gastric - accounts for 30-50 percent of UGIB; risk factors H. pylori, NSAIDs, aspirin, steroids). Oesophagogastric varices (10-20 percent - severe bleeding with high mortality; chronic liver disease with portal hypertension). Mallory-Weiss tear (mucosal tear at gastro-oesophageal junction after forceful vomiting). Oesophagitis and gastritis. Upper GI malignancy (oesophageal, gastric). Dieulafoy lesion (submucosal artery, minimal mucosal defect - difficult to detect). Vascular malformations (angiodysplasia). Aorto-enteric fistula (rare but catastrophic - consider in previous aortic surgery). Portal hypertensive gastropathy.
Presentation
Haematemesis (fresh red or "coffee-ground"), melena (black tarry stool - digested blood from upper GI source, requires around 50 mL to produce), and haematochezia (bright red rectal blood - if massive UGIB with rapid transit).
Symptoms of hypovolaemia
dizziness, syncope, cool peripheries, tachycardia, and hypotension. Chronic occult bleeding may present with iron deficiency anaemia.
Assessment
Take a focused history (previous ulcers, liver disease, alcohol, NSAIDs/aspirin/anticoagulants, retching before haematemesis - suggests Mallory-Weiss). Examine for signs of chronic liver disease (jaundice, spider naevi, gynaecomastia, splenomegaly, ascites, caput medusae - suggests variceal aetiology). Rectal examination for melena.
Risk stratification
Glasgow-Blatchford score (GBS) - pre-endoscopic risk assessment; score 0-1 suggests low risk suitable for outpatient management. Rockall score - includes post-endoscopic findings; predicts rebleeding and mortality.
Investigations
Bloods - FBC (Hb; may be normal initially before haemodilution), urea (raised out of proportion to creatinine from digested blood protein absorption in upper GI bleeding), U&E, LFTs, coagulation, group and crossmatch. Venous blood gas for lactate. Consider ECG. Urgent OGD is diagnostic and therapeutic.
Management
Resuscitation - ABC. Large-bore IV access (two cannulae). IV crystalloid (though avoid over-resuscitation before endoscopy in some settings - permissive hypotension debated). Transfuse packed red cells for haemodynamic instability or Hb below 70 g/L (below 80 g/L if cardiovascular disease per NICE NG24). Correct coagulopathy - platelets if below 50 (or below 100 if active bleeding), FFP if INR above 1.5. Reverse anticoagulants (vitamin K and prothrombin complex concentrate for warfarin; specific reversal for DOACs - idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors; protamine for heparin). Stop antithrombotic medications acutely. Antibiotics (ceftriaxone) for suspected variceal bleeding (reduces infection and mortality per BSG). Terlipressin (2 mg IV then 1-2 mg 4-6 hourly) for suspected variceal bleeding - splanchnic vasoconstrictor; continue for 3-5 days. IV proton pump inhibitor is not routinely recommended pre-endoscopy per NICE.
O
G
D within 24 hours
(immediately after resuscitation in unstable patients).
Non-variceal bleeding
dual endoscopic therapy - adrenaline injection combined with a second modality (thermal - bipolar coagulation, mechanical - clips, or thermal cautery). Sengstaken-Blakemore tube as temporising measure for variceal bleeding not controlled by endoscopy - awaiting definitive management.
Variceal bleeding
endoscopic band ligation for oesophageal varices; injection of glue (cyanoacrylate) for gastric varices. TIPSS (transjugular intrahepatic portosystemic shunt) for refractory variceal bleeding or early re-bleeding.
Post-procedure
IV PPI infusion (omeprazole/pantoprazole 80 mg bolus then 8 mg/hour for 72 hours) for high-risk peptic ulcer stigmata (Forrest classification - active spurting, oozing, non-bleeding visible vessel, adherent clot). Test for H. pylori (during OGD - CLO test) and eradicate if positive. Long-term PPI for peptic ulcer. Restart antithrombotics based on individual risk-benefit. Prevent variceal re-bleeding with non-selective beta-blocker (carvedilol or propranolol) and repeat banding. Alcohol cessation, liver disease optimisation.
Failed endoscopic haemostasis
repeat OGD (rebleed rate 10-20 percent), interventional radiology (arterial embolisation), or surgery (rarely required now).
Prognosis
Rebleeding is a strong prognostic factor. Overall mortality 8-10 percent; up to 20-30 percent in variceal bleeding.
References
NICE CG141 Acute UGIB; BSG guidelines on variceal bleeding.
UK guidance
Every source used for this question, so you can check the detail yourself.
Clinical application
Ensure your endoscopy service has 24/7 access to combination haemostasis kit and expertise - adrenaline alone increases rebleed rates.
