Emergency nursing management of massive upper GI bleed

Anandhi1*, Arputha Mary2, Esthar Rani3

1Nursing Incharge, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

2Assistant Nursing Superintendent, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

3Nursing Superintendent, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

*Correspondence

Abstract

Upper gastrointestinal (GI) bleeding is a life-threatening emergency requiring prompt recognition and multidisciplinary management. This case report describes a 50-year-old male with ethanol-related chronic liver disease who presented with melena and anemia. Endoscopic evaluation revealed bleeding fundal varices, which were successfully managed with endoscopic ultrasound (EUS)-guided coiling and glue therapy. Despite initial stabilization, the patient developed a post-procedural complication requiring close monitoring. Financial constraints led to early discharge against medical advice. This report highlights the importance of early identification, nursing vigilance and addressing underlying causes to improve patient outcomes.

Key words: Upper gastrointestinal (GI) bleeding; Endoscopic ultrasound (EUS); Variceal bleeding

Introduction

Upper GI bleeding is a common emergency, particularly in patients with chronic liver disease and portal hypertension. Variceal bleeding is associated with high morbidity and mortality. Early diagnosis, timely intervention, and effective nursing care play a crucial role in reducing complications and improving survival.

Case presentation

A 50-year-old male patient was apparently normal two days prior to admission, after which he developed black tarry stools (melena) for two days, small in volume with 2–3 episodes.

There was:

  • No history of hematemesis
  • No abdominal distension or pedal edema
  • No jaundice or altered sleep pattern
  • Normal bowel and bladder habits
  • Past history revealed:
  • Umbilical hernia repair (5 years ago)
  • Known case of ethanol-related chronic liver disease

Clinical Examination

On examination

Conscious and oriented, Afebrile

Pulse66/min
Blood Pressure130/80 mmHg
SpO₂98% on room air
Bilateral clubbingPresent
Cardiovascular systemS1, S2 normal
Respiratory systemNormal vesicular breath sounds
AbdomenSoft

Laboratory Investigations

  • Hemoglobin: 8.4 g/dL (low)
  • Reduced RBC count
  • Mild liver function abnormalities
  • Slightly elevated INR
  • Diagnosis

Based on clinical and investigative findings, the patient was diagnosed with: Acute chronic liver failure with bleeding fundal varices leading to upper GI bleeding.

Management

Medical Management

  • Pantoprazole (Pantocid) 40 mg IV
  • Tranexa 1 g
  • Sucralfate
  • Supportive medications including Antihypertensive and Antiepileptic
  • Endoscopic Intervention
  • The patient underwent: EUS-guided coiling and glue therapy.This successfully controlled the bleeding.

Nursing Responsibilities

Initial assessment

  • Airway, breathing, and circulation (ABC) were assessed
  • Continuous monitoring of vital signs
  • Early identification of hypovolemic shock

Monitoring and support

  • Observation for melena and hematemesis
  • Monitoring hemoglobin and coagulation profile
  • Maintaining IV access and fluid management

Post-procedural care

  • Monitoring for rebleeding
  • Assessing complications such as infection or ulceration
  • Ensuring medication compliance

Patient education

  • Advice on alcohol cessation
  • Importance of follow-up
  • Warning signs of rebleeding

Post-procedural course

Post-procedure monitoring initially showed no active bleeding. However, the patient later developed: Fever and Ulcer at the glue injection site. Medication administered accordingly. The patient was stable but required further observation however, due to financial constraints, the patient was discharged against medical advice at request after counseling regarding risks. Health Education was given.

Condition at discharge

Conscious, lethargic, Afebrile

Pulse92/min
BP110/60 mmHg
SpO₂95% on room air

On follow-up, the patient remained stable with no further bleeding episodes. To minimize the risk of recurrent upper gastrointestinal bleeding, the following medical and lifestyle measures were advised:

Medical management

  • Continuing proton pump inhibitors (PPIs) as prescribed to reduce gastric acid secretion
  • Use non-selective beta-blockers (e.g., carvedilol) to reduce portal hypertension
  • Adhere strictly to all prescribed medications, including mucosal protective agents (e.g., sucralfate)
  • Avoid NSAIDs and anticoagulants unless specifically advised by the physician
  • Regular monitoring of hemoglobin and coagulation profile (INR)

Lifestyle modifications

  • Complete abstinence from alcohol to prevent further liver damage
  • Maintain a balanced, soft diet avoiding spicy and irritant foods
  • Ensure adequate hydration and nutrition
  • Avoid heavy lifting or activities that increase intra-abdominal pressure

Follow-Up care

  • Strict adherence to scheduled gastroenterology follow-up
  • Periodic endoscopic surveillance to assess varices
  • Early reporting of symptoms such as:
  • Black tarry stools (melena)
  • Vomiting of blood (hematemesis)
  • Dizziness or syncope
  • Infection and Complication Prevention
  • Monitor for fever or abdominal pain, which may indicate post-procedural complications
  • Maintain good personal hygiene and medication compliance

Patient and family education

  • Educated regarding warning signs of rebleeding
  • Importance of early hospital visits in case of symptoms
  • Counseling regarding disease prognosis and long-term care

Conclusion

This case highlights the importance of early recognition and prompt intervention in managing massive UGI bleeding. Nurses play a crucial role in patient assessment, continuous monitoring, timely intervention, and education. Effective nursing care significantly contributes to improved clinical outcomes and prevention of complications.

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