Acute gastrointestinal bleeding: a case-based approach

The case: blood where it should not be

Our fictional patient, Margaret, aged 72, arrives at A&E after vomiting what looks like coffee grounds and then bright red blood. Over two days she has also passed black, tarry, foul-smelling stools. She takes anti-inflammatory painkillers for her joints. She feels light-headed and her pulse is fast. Vomiting blood (haematemesis) and black tarry stools (melaena) are classic signs of bleeding from the upper gut — the stomach or first part of the small bowel. Fresh red blood from the back passage more often points to lower gut bleeding. The team treats this as a potential emergency and begins assessment and resuscitation together.

How serious is it? Assessing risk

Not all GI bleeds are equal. The team looks at how much blood has been lost and how the patient is coping: pulse, blood pressure, breathing and alertness all matter. A fast pulse and low blood pressure suggest significant loss. They ask about warning factors such as liver disease, previous ulcers, and medicines like anti-inflammatories and blood thinners, which raise the risk. Clinicians use scoring tools to help judge who needs urgent treatment and who might be managed more conservatively. Blood tests check the blood count, clotting and organ function. This structured risk assessment guides how quickly and intensively the team needs to act.

Stabilising the patient

As with any major bleed, the priority is to support the circulation. The team follows an ABCDE approach, gives oxygen if needed, and secures large cannulas into veins to give fluids and, if necessary, blood. They send blood to the laboratory so matched blood can be provided. If the person takes blood-thinning medicines, or has a clotting problem from liver disease, steps are taken to correct this. Close monitoring continues throughout. The aim is to keep the circulation stable and the organs supplied with oxygen while arrangements are made to find and treat the source of the bleeding, ideally with an endoscopy.

Finding and stopping the source

The key investigation for upper GI bleeding is an endoscopy — a thin flexible camera passed through the mouth into the stomach. It lets doctors see the source, such as a stomach ulcer or swollen veins linked to liver disease, and treat it directly, for example by sealing a bleeding vessel. Margaret’s endoscopy shows a stomach ulcer, likely linked to her anti-inflammatory tablets, which is treated during the procedure. Medicines to reduce stomach acid are given. For lower gut bleeding, other tests such as a colonoscopy or scans may be used. Occasionally, if bleeding cannot be controlled, other procedures or surgery are needed.

Recovery and preventing a repeat

After treatment, Margaret is monitored for further bleeding and her blood count is rechecked. The team reviews her medicines: the anti-inflammatory painkiller is stopped or changed, as it likely contributed to the ulcer, and stomach-protecting treatment is arranged. If a bacterium called Helicobacter pylori is found, it is treated, as it is a common cause of ulcers. She is given clear advice on what symptoms should prompt her to seek help again. The wider lesson is that common medicines can cause serious bleeding, so anyone on anti-inflammatories or blood thinners who notices these warning signs should seek urgent medical care.