Dealing with upper gastrointestinal (UGI) bleeding is fraught with pitfalls, not least because spotting those patients who are suffering significant bleeding can be difficult amongst the majority of referrals who are ill and hypotensive for other reasons. Despite diagnostic difficulties and the increasing age and comorbidities of our patients, the mortality rate from UGI bleeding has remained stable over the past 30 years.1–4 The variable mortality rates in published series can be explained by the inclusion of a proportion of healthier patients without a significant bleeding site. For this reason, the best way to assess emergency UGI bleeding outcomes is probably to exclude cases in which there is no significant finding, and only include patients with bleeding ulcers and varices into the calculated 30-day mortality rate. In Leeds we have examined the mortality rate in all patients with bleeding ulcers and varices over a 5-year period and found a 30-day mortality rate of 22%.5
In the absence of non-invasive means to identify patients with genuine bleeding, the benchmark for patients with emergency GI bleeding is to offer an emergency gastroscopy within 24 hours. In the UK, even this permissive benchmark is not always achieved. In a UK National audit,6 only 50% of patients underwent endoscopy within 24 hours of presentation, compared with 76% of patients in a Canadian audit.7
For patients with UGI bleeding, we know that early endoscopy is safe, reduces length of hospital stay and reduces the need for emergency surgery.8–12 However, we have no strong evidence that an early endoscopy saves lives.11–13 This may be as most series are small and largely composed of patients who do not have significant bleeding. Naturally, carrying out an emergency endoscopy in a patient who develops vomiting after commencing antibiotics for a bronchopneumonia is unlikely to make any difference to mortality.
Here, I draw on many years clinical experience to discuss the mistakes most frequently made when dealing with UGI bleeding.