OSCE — acute upper GI bleed resuscitation and risk stratification · MBBS OSCE

Brief (to candidate)

A 60-year-old man vomits a large cupful of fresh blood in the ED. He is sweaty, HR 110, BP 92/58. He drinks heavily and has known hepatitis B. Assess and stabilise him, risk-stratify, and outline immediate medical therapy and endoscopy timing.

Candidate instructions

Perform ABCDE with attention to airway protection.
State vascular access, blood products, and transfusion threshold.
Calculate/interpret Glasgow-Blatchford conceptually.
Branch into variceal vs non-variceal medical therapy.
State endoscopy urgency.

Examiner checklist

Domain	Key actions expected
Airway	Recognises aspiration risk; early intubation if massive ongoing bleed + reduced consciousness
Access / resus	Two large-bore cannulae; balanced crystalloid aliquots; group & crossmatch
Transfusion	Restrictive Hb threshold 7 g/dL (higher if cardiac/massive ongoing)
Risk score	GBS components (urea, Hb, SBP, HR, melaena, syncope, liver/heart disease) — high score → admit/monitor
Variceal bundle	Terlipressin (or octreotide) + antibiotic + early OGD ≤12 h
Ulcer pathway	PPI; endoscopic therapy for high-risk Forrest lesions; H. pylori later
Disposition	Monitored bed/ICU if unstable; massive haemorrhage protocol

Model key actions

Resuscitate before endoscopy.
Assume varices until proven otherwise given liver disease — start vasoconstrictor + antibiotic.
Restrictive transfusion strategy.
Urgent endoscopy after stabilisation.

Common errors

Sending unstable patient to endoscopy without airway/IV access.
Liberal transfusion to normal Hb in variceal bleed.
Omitting antibiotics in cirrhotic bleed.
Using TXA routinely (not supported by HALT-IT).

References2Show

[1]Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet, 2000.PMID 11073021
[2]Villanueva C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. NEJM, 2013.PMID 23281973