Medicine — GI Bleeding and Dyspepsia, NMC MBBS licence examination syllabus (Nepal Medical Council).
Gastrointestinal bleeding and dyspepsia
Resuscitate first, find the source second — and never let a comfortable explanation close the case.
Gastrointestinal bleeding is one of the presentations where the order of operations is the examinable content. Patients do not die of a peptic ulcer or a diverticulum; they die of hypovolaemia. So the first job is always circulatory — access, blood, and an honest assessment of severity — and endoscopy follows once the patient is stable enough for it.
The other half of this chapter is quieter and is where most of the missed cancers are. Dyspepsia and rectal bleeding are extremely common, almost always benign, and occasionally the first sign of a malignancy. The skill is knowing precisely which features move a patient out of the "reassure" group.
🩺 Where this lives: "It's just haemorrhoids" is one of the most costly sentences in clinical practice. Haemorrhoids are so common that most people with colorectal cancer also have them — so finding haemorrhoids explains nothing and excludes nothing. The same logic applies to attributing iron deficiency anaemia to diet in an older man, or dyspepsia to stress in someone losing weight. In each case a plausible benign explanation is available, and accepting it without examining is how early cancers become late ones.
💡 A note on numbers. This chapter gives no doses, no eradication regimens and no risk-score thresholds. Helicobacter pylori regimens depend on local resistance patterns and national guidance, and the scoring systems used to stratify upper GI bleeding differ between institutions. Variceal bleeding and portal hypertension are covered in the Chronic Liver Disease chapter, shock in its own chapter, NSAID adverse effects in the Analgesics chapter, and perforation in the Acute Abdomen chapter.
Upper or lower?
Two points are worth holding. Melaena means upper gastrointestinal bleeding, and it means a significant volume — blood has to be digested to turn black and offensive, which takes both time and quantity. And the reverse trap: a very brisk upper bleed can present as fresh red blood per rectum, because there is no time for digestion. If a patient with rectal bleeding is shocked, think upper source rather than assuming a colonic one.
Resuscitation comes first
THE ORDER OF PRIORITIES
1. ASSESS THE CIRCULATION, not the story. Tachycardia and
a postural blood pressure drop come BEFORE hypotension
— the shock chapter applies directly here, and young
patients compensate until they suddenly do not.
2. TWO LARGE CANNULAE. Crossmatch. Send full blood count,
urea and electrolytes, liver tests and CLOTTING.
3. FLUID, THEN BLOOD as indicated by physiology and local
transfusion policy.
4. STOP THE CONTRIBUTORS. NSAIDs and antiplatelets stopped;
anticoagulation reviewed urgently with senior input,
balancing bleeding against the reason it was prescribed.
5. ENDOSCOPY once resuscitated — it is both diagnostic and
therapeutic, and the timing follows local pathways.
TWO LABORATORY TRAPS:
A NORMAL HAEMOGLOBIN EARLY MEANS NOTHING. In acute
haemorrhage the patient loses whole blood; the
concentration falls only as the plasma volume is
restored. Do not be reassured by a normal first result.
A RAISED UREA with normal creatinine in upper GI bleeding
reflects absorbed blood protein, and supports an upper
source.
IF THE PATIENT HAS KNOWN LIVER DISEASE, consider VARICEAL
bleeding — the management pathway differs and is covered in
the Chronic Liver Disease chapter.
Peptic ulcer disease
💡 Exam angle: the two dominant causes are Helicobacter pylori and NSAIDs, and the practical point about NSAIDs is that patients frequently do not report them. Over-the-counter analgesics, low-dose aspirin and traditional remedies are often not counted as "medicines" when you ask what someone takes — so ask specifically. NSAID-related ulcers are also often painless until they bleed, particularly in older patients, which removes the warning you might expect.
Dyspepsia and the alarm features
The alarm features are worth memorising precisely, because they are exactly what a question stem will describe: dysphagia, weight loss, persistent vomiting, gastrointestinal bleeding or anaemia, an epigastric mass, progressive symptoms, and new dyspepsia in an older patient. Any one of them moves the patient from empirical treatment to urgent endoscopy. Dysphagia in particular is never treated empirically — difficulty swallowing, especially if progressive and worse for solids, is oesophageal malignancy until excluded.
Rectal bleeding
WHEN RECTAL BLEEDING NEEDS INVESTIGATION
ALWAYS EXAMINE. Abdominal examination and a rectal
examination are not optional, and finding haemorrhoids does
not complete the assessment — most people with colorectal
cancer also have haemorrhoids.
FEATURES THAT POINT AWAY FROM A BENIGN CAUSE:
CHANGE IN BOWEL HABIT, particularly looser or more
frequent stools persisting
Blood MIXED IN with the stool rather than on the surface
or on the paper
WEIGHT LOSS
IRON DEFICIENCY ANAEMIA
An abdominal or rectal mass
Older age
IRON DEFICIENCY ANAEMIA deserves its own emphasis. In a
MAN of any age, or a POST-MENOPAUSAL WOMAN, unexplained
iron deficiency anaemia is gastrointestinal blood loss
until proven otherwise and requires investigation of the
gut — even with no visible bleeding at all. Attributing it
to diet is a recognised route to a late diagnosis.
In younger women, menstrual loss is a common explanation —
but it should still be a considered conclusion rather than
an assumption.
Clinical reasoning: four presentations
🔍 Case 1 — reassured by a normal haemoglobin
PresentationA 40-year-old vomits a large volume of fresh blood. He is pale and sweaty with a pulse of 118 and a systolic pressure of 112. His initial haemoglobin is normal, and the team plans to observe him on the ward.
TrapBelieving an early haemoglobin.
ReasoningIn acute haemorrhage whole blood is lost, so the concentration does not fall until plasma volume is restored. His tachycardia and appearance are the real information — he is compensating.
AnswerResuscitate actively: two large cannulae, crossmatch and clotting, fluid and blood per protocol, senior involvement, and arrange endoscopy. Judge severity by physiology, not by the first haemoglobin.
🔍 Case 2 — the tablets that are not medicines
PresentationA 72-year-old presents with melaena. Asked what medication he takes, he says none. Later his daughter mentions he buys painkillers for his knees most weeks and takes a small aspirin daily.
Key omissionNSAIDs and aspirin, unreported.
ReasoningPatients frequently do not count over-the-counter analgesics or low-dose aspirin as medicines. NSAID ulcers in older patients are often painless until they bleed, so there may be no preceding dyspepsia.
AnswerAsk specifically about over-the-counter and traditional remedies in every patient. Resuscitate, stop the NSAID and review the aspirin with senior input, and arrange endoscopy.
🔍 Case 3 — difficulty swallowing
PresentationA 61-year-old has three months of dyspepsia and now finds solid food sticks. He has lost weight. He is prescribed acid suppression and asked to return in eight weeks if no better.
Two alarm featuresDysphagia and weight loss.
ReasoningProgressive dysphagia for solids with weight loss in this age group is oesophageal malignancy until excluded. Empirical acid suppression may relieve symptoms temporarily and delay the diagnosis by weeks.
AnswerUrgent endoscopy. Dysphagia is never treated empirically.
🔍 Case 4 — anaemia blamed on the diet
PresentationA 66-year-old man is found to have iron deficiency anaemia. He has no visible bleeding and reports no bowel symptoms. He is started on iron and told his diet is probably inadequate.
ErrorExplaining away unexplained iron deficiency.
ReasoningIn a man of any age, or a post-menopausal woman, unexplained iron deficiency anaemia is gastrointestinal blood loss until proven otherwise — and occult bleeding is by definition invisible.
AnswerTreat the iron deficiency and investigate the gastrointestinal tract per local pathway. Iron replacement without investigation corrects the number and hides the cause.
Commonly confused
Confusion
The distinction
Why it matters
Melaena vs fresh rectal blood
Black means digested, so upper and substantial
Localises the source and indicates volume.
Fresh rectal blood vs lower source
A brisk upper bleed can look fresh
If shocked, think upper.
Normal haemoglobin vs no blood loss
Concentration falls late
Judge severity by physiology.
Raised urea vs renal failure
Absorbed blood protein in upper GI bleeding
Supports an upper source.
Dyspepsia vs alarm features
Dysphagia, weight loss, vomiting, bleeding, mass
Moves the patient to urgent endoscopy.
Empirical treatment vs dysphagia
Dysphagia is never treated empirically
It delays a cancer diagnosis.
Haemorrhoids vs a complete assessment
Having haemorrhoids excludes nothing
Most colorectal cancers coexist with them.
Dietary vs occult GI iron deficiency
In men and post-menopausal women, investigate
Occult bleeding is invisible by definition.
Rapid revision
MUST-KNOW FACTS
1. RESUSCITATE FIRST, diagnose second — patients die of hypovolaemia.
2. HAEMATEMESIS and MELAENA indicate an UPPER source.
3. MELAENA means blood has been digested — upper, and a significant volume.
4. A brisk UPPER bleed can present as FRESH rectal blood.
5. If a patient with rectal bleeding is SHOCKED, think upper source.
6. Assess severity by TACHYCARDIA and postural drop, not the story.
7. A NORMAL EARLY HAEMOGLOBIN MEANS NOTHING.
8. RAISED UREA with normal creatinine supports an upper GI bleed.
9. Two large cannulae, crossmatch, and send CLOTTING.
10. STOP NSAIDs and antiplatelets; review anticoagulation with seniors.
11. Endoscopy when resuscitated — diagnostic and therapeutic.
12. Known liver disease — consider VARICES; see that chapter.
13. Peptic ulcer: the two dominant causes are H. PYLORI and NSAIDs.
14. Eradicating H. pylori prevents ulcer recurrence.
15. H. pylori is also a gastric cancer risk factor.
16. Patients do NOT report over-the-counter NSAIDs — ask specifically.
17. NSAID ulcers are often PAINLESS until they bleed.
18. Complications: bleeding, PERFORATION, gastric outlet obstruction.
19. Perforation is a surgical emergency.
20. ALARM FEATURES: DYSPHAGIA, weight loss, persistent vomiting.
21. Also GI bleeding or anaemia, epigastric mass, progressive symptoms.
22. New dyspepsia in an OLDER patient is itself an alarm feature.
23. DYSPHAGIA IS NEVER TREATED EMPIRICALLY.
24. Epigastric pain can be CARDIAC — consider the heart.
25. NEVER blame rectal bleeding on haemorrhoids without examining.
26. Most people with colorectal cancer also have haemorrhoids.
27. Cancer features: CHANGE IN BOWEL HABIT, blood MIXED IN, weight loss.
28. IRON DEFICIENCY ANAEMIA in a man or post-menopausal woman — investigate the gut.
29. Occult bleeding is invisible — no visible blood proves nothing.
30. Abdominal AND rectal examination in every case.
💡 Exam angle: this chapter rewards refusing the easy explanation. The normal haemoglobin, the reported absence of medication, the haemorrhoids, the "dietary" anaemia — each is a plausible reason to stop looking, and each is the wrong answer.
Syllabus points
Distinguishing upper from lower bleeding
Why melaena means upper and substantial
Brisk upper bleeds looking fresh
Resuscitation before diagnosis
Why an early haemoglobin misleads
Raised urea as a clue
Peptic ulcer: H. pylori and NSAIDs
Why NSAID use goes unreported
Ulcer complications
The alarm features in dyspepsia
Why dysphagia is never treated empirically
Rectal bleeding and the haemorrhoid trap
Iron deficiency anaemia and the gut
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