Upper Gastrointestinal Bleeding: Recognising Haematemesis and Melaena, and Nursing Care

Upper gastrointestinal (GI) bleeding, from the oesophagus, stomach or duodenum, is a common medical emergency. The commonest causes are peptic ulcers (often linked to NSAIDs, aspirin or H. pylori infection) and, in people with liver cirrhosis, oesophageal varices. In parts of Africa and Asia, varices due to liver disease from hepatitis B and schistosomiasis are a major cause. Bleeding can be sudden and massive.

Recognising a GI bleed

• Haematemesis: vomiting fresh red blood or “coffee-ground” material.
• Melaena: black, tarry, sticky, foul-smelling stool. Iron tablets cause black stools too, but these are not tarry or sticky.
• Signs of shock: rising heart rate, falling BP, pallor, sweating, dizziness on standing, confusion, reduced urine output.
• Rapid upper GI bleeding can also cause bright red blood from the rectum.

Immediate nursing actions

1. Call for help. A–E assessment.
2. Airway: position on the side if vomiting and drowsy; have suction ready.
3. Two large-bore IV cannulas; bloods: full blood count, urea and electrolytes, liver function, clotting, group and crossmatch.
4. IV fluids and blood transfusion as prescribed. Many guidelines use a restrictive transfusion approach (e.g. transfusing to a target haemoglobin of 70–80 g/L in stable patients), but massive bleeding needs rapid transfusion.
5. Nil by mouth pending endoscopy.
6. Frequent observations; strict fluid balance; urinary catheter if unstable.
7. Stop or flag anticoagulants, antiplatelets and NSAIDs to the medical team.

Risk scoring

The Glasgow-Blatchford score uses urea, haemoglobin, systolic BP, heart rate, melaena, syncope, liver disease and heart failure to estimate who needs intervention. Patients with a score of 0–1 may be suitable for outpatient management in some guidelines; higher scores need admission and endoscopy.

Endoscopy

Upper GI endoscopy identifies the source and allows treatment (injection, clips, heat, banding of varices). Unstable patients need endoscopy immediately after resuscitation; others usually within 24 hours. Prepare the patient: fasting, consent, IV access, and monitor during and after sedation.

Variceal bleeding

In patients with known or suspected liver cirrhosis, variceal bleeding is often severe. In addition to resuscitation, medical teams typically prescribe:

• Terlipressin (or similar) to reduce portal pressure.
• Prophylactic antibiotics, which reduce infection and death.
• Endoscopic band ligation.

Watch for hepatic encephalopathy (confusion, drowsiness) and low blood glucose in patients with liver disease.

After the bleed

• Proton pump inhibitors (e.g. omeprazole) for ulcer bleeding after endoscopy, as prescribed.
• Test and treat for H. pylori.
• Review NSAID and aspirin use. Many patients don’t realise over-the-counter painkillers can cause ulcers.
• Watch for rebleeding: new haematemesis or melaena, rising pulse, falling BP or haemoglobin.
• Alcohol support where relevant; hepatitis B testing and liver follow-up for variceal bleeds.

Related: Blood transfusion · Hepatitis B · Alcohol withdrawal

Based on NICE CG141 (Acute upper gastrointestinal bleeding in over 16s) and British Society of Gastroenterology guidance. Educational content: follow local protocols.