Upper Gi Bleed
Upper gastrointestinal bleeding is hemorrhage originating from a source proximal to the ligament of Treitz, commonly caused by peptic ulcers, esophageal varices, or Mallory-Weiss tears, presenting with hematemesis or melena.
History Taking: Upper GI Bleed (UGIB)
This is the one condition where you should look at the patient before asking a single question. A haemodynamically unstable patient needs resuscitation first. [1][2]
Assess urgency [2]:
- Very severe: hypotension, tachycardia, agitation, confusion, drowsiness, coma
- Moderate to severe: postural hypotension (indicates ≥20% blood volume loss)
- Note that Hb does not drop until expansion of ECV (takes ≥24h → does NOT reflect acute degree of blood loss) [2]
Resuscitate Before You Interrogate
A classic OSCE pitfall: students launch into a full history while the simulated patient is "in shock." Examiners expect you to state "I would first assess haemodynamic stability and initiate resuscitation if needed" before proceeding with history taking.
Before assuming UGIB, briefly exclude mimics:
| Mimic | How to differentiate |
|---|---|
| Haemoptysis (咯血) | Associated with cough, frothy, bright red (aerated), no melaena [2] |
| Swallowed blood (e.g. epistaxis, oral bleeding) | Recent nosebleed or dental procedure |
| Iron / bismuth stools | Constipated, green-black solid stools with granules on PR; no pungent melaena smell [2] |
Practical phrasing:
- "Have you had any nosebleeds or coughed up blood recently?" (你最近有冇流鼻血或者咳血？)
- "Are you taking any iron tablets?" (你有冇食鐵丸？)
Why this matters: Misidentifying haemoptysis as haematemesis changes the entire diagnostic pathway. Iron stools are a common cause of unnecessary endoscopy referrals.
Step 2: Characterise the Bleed
This is the meat of the presenting complaint. You need to nail down the nature, amount, timing, and progression.
| Presentation | What it means | Cantonese phrasing |
|---|---|---|
| Haematemesis (嘔血) | Vomiting of fresh red blood → moderate-to-severe, possibly ongoing [2] | "你嘔嘅嘢係咩顏色？有冇鮮血？" |
| Coffee-ground vomiting (嘔啡色嘢/似咖啡渣) | Blood oxidized by gastric acid → milder/slower bleed from stomach or beyond [2] | "嘔出嚟似唔似咖啡渣咁？" |
| Melaena (黑便/柏油便) | Black, tarry, loose, extremely malodorous stools → usually UGIB, can arise up to right colon [2] | "大便係唔係好黑好臭，好似芝麻糊咁？" |
| Haematochezia (便血) | Fresh red blood per rectum → usually LGIB but can occur with massive UGIB (with signs of hypovolaemia) [2] | "大便有冇鮮血？" |
Fresh vs Stale Melaena
On PR examination, fresh melaena (haematin + Hb) is jet-black, tarry, non-particulate liquid → indicates acute ongoing bleeding. Old/stale melaena (haematin only) is black-grey, dull, mixed with normal stool → indicates bleeding has likely stopped. [2]
- "How many times have you vomited blood?" (你嘔咗幾多次血？)
- "Can you estimate the amount — a teaspoon, a cup, a bowl?" (大約幾多？一茶匙？一杯？一碗？)
- "When did this first start?" (幾時開始？)
- "Is it getting worse, staying the same, or improving?" (有冇越嚟越嚴重？)
Why this matters: The nature, rate, and duration of bleeding directly determines urgency and guides timing of endoscopy. [1][3]
You cannot measure blood loss directly. You infer it from symptoms of hypovolaemia. Anaemic symptoms are UNCOMMON in acute UGIB because both plasma and blood cells are lost simultaneously. [4]
| Symptom | Cantonese | Significance |
|---|---|---|
| Dizziness / lightheadedness (頭暈) | "你有冇頭暈？" | Postural hypotension |
| Syncope / fainting (暈倒) | "你有冇暈低過？" | Significant volume loss |
| Palpitations (心跳) | "有冇覺得心跳好快？" | Sympathetic response |
| Cold sweats / clamminess (出冷汗) | "有冇出冷汗？手腳凍唔凍？" | Peripheral vasoconstriction |
| Thirst (口渴) | "覺唔覺得好口渴？" | Dehydration |
| Confusion / agitation (神志不清) | "有冇覺得個人矇查查？" | Cerebral hypoperfusion — RED FLAG |
| Reduced urine output (小便少咗) | "小便有冇少咗？" | End-organ hypoperfusion |
Features of ongoing bleeding [1]:
- Continued haematemesis
- Haematochezia
- Fresh PR bleeding
- Fresh blood aspirated from NG tube
- Persistent tachycardia
Step 4: Determine Aetiology — Focused Differentiating Questions
The key clinical fork in the road is variceal vs non-variceal UGIB, because management differs enormously.
Variceal bleeds are usually profuse and present as haematemesis. [2] Only 50% stop spontaneously (cf > 90% in non-variceal causes). [5]
| Question | Cantonese | Why you ask |
|---|---|---|
| History of liver disease / cirrhosis | "你有冇肝病？肝硬化？" | Direct cause of portal hypertension → varices |
| Hepatitis B/C carrier status | "你係唔係乙型/丙型肝炎帶菌者？" | Commonest cause of CLD in HK |
| Jaundice | "有冇眼黃、皮膚黃？" | Liver decompensation |
| Abdominal distension / ascites | "個肚有冇脹大咗？" | Portal hypertension |
| Easy bruising | "容唔容易瘀？" | Coagulopathy from liver failure |
| Previous variceal bleed / OGD / banding | "之前有冇試過靜脈曲張出血？有冇做過胃鏡綁帶？" | Known portal HTN |
| Alcohol history | "你飲唔飲酒？飲幾多？飲咗幾耐？" | Alcoholic liver disease [3][6] |
PUD is the commonest cause of UGIB (25-50%). [2] Four major risk factors: H. pylori + NSAIDs + Stress + Excess gastric acid. [1]
| Question | Cantonese | Why you ask |
|---|---|---|
| Epigastric pain, relation to meals | "食嘢之前或者之後有冇胃痛？" | GU worsened by food; DU relieved by food then recurs [4] |
| History of dyspepsia | "有冇經常胃脹、胃酸倒流？" | Pre-existing peptic disease |
| Previous H. pylori testing & treatment | "有冇驗過幽門螺旋桿菌？食過殺菌藥未？" | Documented eradication vs persistent infection [1] |
| NSAID / aspirin use | "你有冇食止痛藥、亞士匹靈？" | Key modifiable risk factor [3] |
| Recent physiological stress (ICU, burns, head injury) | "最近有冇住過深切治療部、受過傷？" | Curling ulcer (burns), Cushing's ulcer (↑ICP) [2] |
| Question | Why you ask |
|---|---|
| Forceful/prolonged vomiting or retching BEFORE haematemesis | Mallory-Weiss = longitudinal mucosal laceration at GEJ from sudden ↑intra-abdominal pressure [1] |
| Binge drinking episode | Common precipitant |
- "嘔血之前有冇嘔咗好多次先？"
| Question | Cantonese | Why you ask |
|---|---|---|
| Dysphagia | "吞嘢有冇困難？" | Oesophageal / gastric cardia CA |
| Early satiety | "食少少就覺得好飽？" | Gastric CA |
| Unintentional weight loss | "體重有冇無端端輕咗好多？" | Constitutional symptom — RED FLAG [4] |
| Loss of appetite (食慾不振) | "有冇冇胃口？" | Constitutional symptom |
| Fatigue (疲倦) | "覺唔覺得成日好攰？" | Anaemia / cachexia |
| Diagnosis | Key question | Why |
|---|---|---|
| Oesophagitis / oesophageal ulcer | GERD symptoms, dysphagia, odynophagia | Erosive oesophagitis from chronic reflux [1] |
| Portal hypertensive gastropathy | Known CLD, ascites | Complication of portal HTN distinct from varices [1] |
| Angiodysplasia | Advanced age, Hx of CKD, aortic valve disease, hereditary haemorrhagic telangiectasia, prior RT | Dilated submucosal vessels; often elderly [2] |
| Aorto-enteric fistula | Previous AAA repair with graft | Medical emergency; high mortality; D3/4 duodenum [1][2] |
| Dieulafoy's lesion | Recurrent UGIB with no clear source on prior OGD | Aberrant submucosal vessel, proximal stomach [1] |
| Hemobilia | Previous liver biopsy or biliary instrumentation | Bleeding from hepatobiliary tract [1] |
Step 5: Background History
| Condition | Why it matters |
|---|---|
| Peptic ulcer disease — including H. pylori status, treatment, documented eradication | Recurrence is the concern [1] |
| Chronic liver disease | Portal HTN → varices, coagulopathy [1] |
| Congestive heart failure | Fluid overload risk during resuscitation [1] |
| Chronic kidney disease | Predisposition to angiodysplasia; fluid overload risk [1] |
| Bleeding disorders / coagulopathy | Platelet dysfunction worsens haemorrhage [1] |
| Previous irradiation | Radiation enteritis [3] |
| Hereditary haemorrhagic telangiectasia | Angiodysplasia [1] |
This is a high-yield area and frequently tested in OSCEs.
| Drug | Why | Cantonese |
|---|---|---|
| Aspirin / NSAIDs | Peptic ulcer → most important modifiable risk factor [1][3] | "有冇食亞士匹靈或者消炎止痛藥？" |
| Anticoagulants (warfarin, DOACs) | Bleeding diathesis [1][3] | "有冇食薄血丸？" |
| Antiplatelet agents (clopidogrel, ticagrelor) | Bleeding diathesis [3] | "有冇食抗血小板藥？" |
| Beta-blockers | May mask tachycardia in shock [3] | "有冇食心臟藥？" |
| Corticosteroids | ↑Risk of NSAID-induced PUD when co-prescribed; TCM may contain hidden steroids [1] | "有冇食類固醇？有冇食中藥？" |
| Iron supplements | Cause black stools — mimic melaena [1][3] | "有冇食鐵丸？" |
| PPIs | Already on treatment — suggests known ulcer disease | "有冇食胃藥？" |
| TCM (中藥) | May contain steroids; herbal interactions [1] | "有冇食中藥？" |
Beta-blockers Mask Tachycardia
If the patient is on beta-blockers, they may NOT mount an appropriate tachycardia despite significant blood loss. Their heart rate may be misleadingly "normal." Always check the drug history before interpreting vital signs. [3]
- "Are you allergic to any medications?" (你有冇對任何藥物敏感？)
- Important before endoscopy, sedation, and potential blood transfusion.
| Question | Why |
|---|---|
| Family history of GI cancer | ↑Risk of upper GI malignancy |
| Family history of liver disease / HCC / hepatitis | HBV is vertically transmitted in HK |
| Family history of bleeding disorders | Inherited coagulopathies |
| Factor | Why | Cantonese |
|---|---|---|
| Alcohol — type, amount, duration, CAGE | Alcoholic liver disease → varices; also gastritis and malignancy [1][3] | "你飲酒嗎？飲幾多？飲咗幾多年？" |
| Smoking — pack-years | Risk factor for PUD and upper GI malignancy [1] | "你食唔食煙？食咗幾耐？每日幾多支？" |
| Occupation | Stress, exposure | |
| Living situation / functional baseline | Important for discharge planning | "你平時自己行得走得？有冇人照顧你？" |
These findings should prompt immediate escalation and consideration for emergency OGD or surgical referral:
| Red Flag | Action |
|---|---|
| Haemodynamic instability (SBP ≤90, HR ≥120) despite resuscitation | Emergency OGD / surgical referral [3] |
| Massive haematemesis with fresh PR bleed | Profuse rapid bleed — likely variceal or major arterial [4] |
| Confusion / decreased consciousness | Cerebral hypoperfusion or hepatic encephalopathy |
| Known varices with profuse haematemesis | Start IV terlipressin empirically before endoscopy [5] |
| Suspected aorto-enteric fistula (herald bleed → massive bleed) | Immediate surgical consultation |
| Hb < 8.0 g/dL on presentation, shock, need for transfusion | Risk factors for recurrent bleeding [1] |
| Age > 60 with coagulopathy | Higher rebleed and mortality risk [1] |
| System | Questions | Why |
|---|---|---|
| GI | Abdominal pain, nausea, vomiting, dysphagia, odynophagia, change in bowel habit, weight change | Cover full GI differential |
| Hepatobiliary | Jaundice, dark urine, pale stools, pruritus, abdominal distension | Liver disease / portal HTN |
| Haematological | Easy bruising, prolonged bleeding from cuts, heavy periods | Coagulopathy / platelet disorder |
| Cardiovascular | Chest pain, SOB on exertion | Anaemia-related angina; cardiac comorbidity |
| Constitutional | Fever, night sweats, weight loss, fatigue | Malignancy, infection |
Common OSCE Pitfalls
- Not assessing urgency first — launching into history while the patient is unstable.
- Forgetting to ask about beta-blockers — interpreting a "normal" HR as reassuring when it's pharmacologically suppressed.
- Not distinguishing melaena from iron stools — always ask about iron supplements and bismuth.
- Missing the AAA repair history — aorto-enteric fistula is rare but fatal; one question can save a life.
- Assuming haematochezia = LGIB — massive UGIB can present with fresh PR blood (with associated hypovolaemia).
- Not asking about previous H. pylori testing AND documented eradication — testing positive once doesn't mean it was successfully treated.
- Forgetting TCM — traditional Chinese medicine may contain hidden steroids and is very relevant in Hong Kong.
- Not asking about alcohol in a culturally sensitive way — frame it neutrally: "Some people drink socially; can I ask about your drinking habits?"
| Tip | Explanation |
|---|---|
| Glasgow-Blatchford score predicts need for endoscopy | Uses admission data (Hb, BUN, SBP, HR, melaena, syncope, liver disease, cardiac failure) — a score of 0 means very low risk, may not need inpatient endoscopy [2] |
| Rockall score predicts rebleeding and mortality | Calculated pre- and post-endoscopy; includes age, shock, comorbidity, diagnosis, signs of recent haemorrhage → ≤2/11 = low risk of rebleed [2] |
| AIMS65 predicts in-hospital mortality | Albumin < 30, INR > 1.5, altered Mental status, SBP ≤90, age > 65 [2] |
| Hb is unreliable acutely | Does not drop until haemodilution occurs (~24h); BUN/Cr ratio elevation is more suggestive of UGIB |
| Variceal bleed has worse prognosis | Only 50% stop spontaneously; highest rebleed risk in first 48-72h [5] |
| Child-Pugh class C = worse outcome in variceal bleed | More likely to have ongoing bleed and higher mortality [5] |
"Mr Chan is a 62-year-old gentleman who presented to Queen Mary Hospital A&E this evening with profuse haematemesis and melaena since this afternoon. He reports vomiting approximately three cups of fresh red blood over the past 6 hours, associated with passage of jet-black tarry stools on two occasions. He also describes dizziness on standing and one syncopal episode at home. He denies any preceding retching, abdominal pain, dysphagia, or weight loss.
In terms of past medical history, he has known hepatitis B carrier status diagnosed 20 years ago but has not been on regular follow-up. He has no history of prior endoscopy, variceal banding, or previous GI bleeding episodes. He has hypertension managed with amlodipine. He has no past surgical history.
Regarding medications, he takes amlodipine 5 mg daily and has been using over-the-counter ibuprofen regularly for knee pain over the past two months. He has no known drug allergies. He is not taking any anticoagulants, antiplatelets, or iron supplements. He does take occasional Chinese herbal remedies.
Family history is significant for his father who died of hepatocellular carcinoma at age 65.
Socially, Mr Chan is a retired construction worker. He drinks approximately 4 cans of beer daily and has done so for over 30 years. He has a 40 pack-year smoking history. He lives with his wife and is independently mobile at baseline.
In summary, Mr Chan is a 62-year-old gentleman with risk factors for both variceal bleeding — chronic HBV, significant alcohol history — and peptic ulcer disease — regular NSAID use, smoking — who presents with a significant acute upper GI bleed with haemodynamic compromise. I would prioritise haemodynamic resuscitation and arrange an urgent OGD."
High Yield Summary
Upper GI Bleed = bleeding proximal to the ligament of Treitz. The two most important aetiological categories are variceal (portal HTN / liver disease) and non-variceal (PUD being the commonest at 25-50%). Always:
- Assess urgency and resuscitate first before detailed history taking.
- Characterise the bleed: haematemesis vs coffee-ground vs melaena; amount, frequency, duration.
- Determine aetiology: Variceal (liver disease, HBV/HCV, alcohol) vs PUD (NSAIDs, H. pylori, stress) vs Mallory-Weiss (preceding retching) vs Malignancy (dysphagia, weight loss, early satiety) vs Rare causes (aorto-enteric fistula, Dieulafoy, angiodysplasia).
- Drug history is critical: NSAIDs, aspirin, anticoagulants, antiplatelets, beta-blockers, iron, TCM.
- Red flags: haemodynamic instability, massive/ongoing bleed, confusion, Hb < 8, known varices, AAA graft history.
- Risk scores: Glasgow-Blatchford (need for endoscopy), Rockall (rebleed/mortality), AIMS65 (in-hospital mortality).
- Hb is unreliable in the acute setting — does not drop for ~24h.
Active Recall - History Taking
[1] Senior notes: felixlai.md (Upper GI bleeding section) [2] Senior notes: Ryan Ho GI.pdf (Section B: Approach to Upper GI Bleed, pp. 40-47) [3] Lecture slides: GC 198. Profuse vomiting of fresh blood and in shock severe upper GI bleeding.pdf (pp. 11-12, 19) [4] Senior notes: maxim.md (Section 3.3 UGIB) [5] Senior notes: Ryan Ho GI.pdf (Variceal haemorrhage management, p. 325) [6] Senior notes: Ryan Ho Fundamentals.pdf (pp. 250-257)
Peripheral Arterial Disease
Peripheral arterial disease is a chronic atherosclerotic narrowing or occlusion of the arteries supplying the extremities, most commonly the lower limbs, leading to reduced perfusion and symptoms ranging from intermittent claudication to critical limb ischemia.
Varicose Veins
Varicose veins are dilated, tortuous superficial veins, most commonly in the lower extremities, resulting from incompetent venous valves and increased intraluminal pressure.