Management of massive gastrointestinal haemorrhage

Gastrointestinal (GI) haemorrhage is a common medical emergency, with one patient presenting every 6 minutes in the UK (70–90,000 cases per year). It is associated with a significant mortality rate that has remained relatively static at 10% for more than two decades. Haemorrhage is commonly categorized as bleeding of upper or lower GI origin, but for organization of care, both groups should be regarded as one clinical entity. Rapid assessment, resuscitation and correction of coagulopathy should be undertaken, following local major haemorrhage protocols, with investigation urgently arranged. For upper GI haemorrhage, endoscopy remains the gold standard for simultaneous investigation and treatment. For lower GI haemorrhage, a more nuanced algorithm is available, including CT angiography for actively bleeding or unstable patients, and endoscopic evaluation in select cases. Clinicians may utilize a range of endoscopic and radiological techniques to diagnose and control the source of haemorrhage, which should be tailored to the site of bleeding and pathology. When haemostasis is not achieved, either repeat intervention or a different modality should be selected. Surgery is now infrequently used as a treatment for GI haemorrhage and should be contemplated only once endoscopic and radiological treatments have failed, following discussion between senior clinicians. Postoperative GI bleeding may still be best served with return to theatre, but interventional radiology should also be considered.