Upper GI bleed — scores, restrictive transfusion and two pathways

Pathway. Without liver-disease stigmata this is a non-variceal presentation (peptic ulcer until proven otherwise). Admission urea and haemoglobin feed the Blatchford read alongside vitals and comorbidity.

Scores.

• Glasgow-Blatchford predicts need for intervention from urea, Hb, SBP, pulse, melaena, syncope, hepatic disease, cardiac failure. Score 0 to 1 marks very-low-risk (outpatient pathway); this patient scores well above 1 (urea, tachycardia, melaena) → admit for endoscopy within 24 hours.^[1][12]
• Rockall (pre-endoscopic: age, shock, comorbidity; complete adds diagnosis and stigmata) predicts mortality.
• AIMS65 (albumin, INR, mental status, SBP ≤90, age over 65) predicts in-hospital mortality simply.
• Forrest at endoscopy: Ia spurting, Ib oozing, IIa visible vessel, IIb clot → combination endoscopic therapy; IIc/III low risk.

Transfusion. Do not transfuse this Hb 98 stable patient yet. Restrictive below 7 g/dL beats liberal below 9: survival 95 vs 91 percent, rebleed 10 vs 16 percent, gradient flat vs risen.^[2] Consensus: below 80 without cardiovascular disease, higher with it.^[13]

Non-variceal drugs. Omeprazole 80 mg IV bolus then 8 mg/h for 72 hours after haemostasis — rebleed 6.7 vs 22.5 percent.^[8] Endoscopy within 24 hours (6-hour urgency adds nothing).^[13] Epinephrine plus thermal (RR 0.49) or mechanical (RR 0.31) second method — never alone.^[14] Continue aspirin 80 mg after control: mortality 1.3 vs 12.9 percent vs rebleed 10.3 vs 5.4 percent.^[4]

If she instead had cirrhosis + haematemesis (variceal pathway).

• Vasoactive immediately for up to 5 days plus prophylactic antibiotics on arrival.
• Urgent endoscopy with band ligation; severe rebleed takes covered TIPSS first; balloon bridges refractory episodes.
• Early TIPSS within 72 hours for Child B-active or Child C under 14.
• Same restrictive transfusion — liberal raises the portal gradient within 5 days.