A 58-year-old man with a 10-year history of cirrhosis presents with hematemesis and melena. He is haemodynamically stable after initial resuscitation. Which investigation is most appropriate to confirm the diagnosis and guide immediate management?

Explanation

## Investigation of Choice in Upper GI Bleeding **Key Point:** Upper gastrointestinal endoscopy (OGD) is the gold standard investigation for suspected upper GI bleeding — it is both diagnostic and therapeutic. ### Why OGD is Superior 1. **Diagnostic accuracy**: Directly visualizes the bleeding source (varices, ulcers, erosions, Mallory–Weiss tears) 2. **Therapeutic capability**: Allows immediate intervention (variceal ligation, sclerotherapy, hemoclip placement, injection therapy) 3. **Timing**: Should be performed within 12 hours of presentation (ideally <6 hours in variceal bleeding) 4. **Prognostic information**: Identifies high-risk stigmata (active bleeding, non-bleeding visible vessel, adherent clot) ### Clinical Context In this cirrhotic patient with hematemesis and melena: - The presentation strongly suggests **variceal bleeding** (most common cause of UGI bleeding in cirrhosis) - OGD allows simultaneous diagnosis and therapeutic intervention (variceal band ligation or sclerotherapy) - Haemodynamic stability permits safe endoscopy after appropriate resuscitation **High-Yield:** OGD has sensitivity >90% for identifying the bleeding source and is the standard of care in all patients with acute UGI bleeding. ### Comparison with Other Investigations | Investigation | Role | Limitation | | --- | --- | --- | | OGD | Diagnostic + therapeutic | Gold standard, first-line | | CT angiography | Detects active bleeding, vascular anatomy | Delayed, non-therapeutic, not first-line | | Barium swallow | Contraindicated in acute bleeding | Risk of aspiration, no therapeutic option | | Abdominal ultrasound | Assesses portal hypertension, cirrhosis | Cannot identify bleeding source, non-urgent | **Clinical Pearl:** Proton pump inhibitor (PPI) infusion should be started before endoscopy in suspected peptic ulcer disease; vasoactive drugs (terlipressin/octreotide) should be started before endoscopy in suspected variceal bleeding.