01Purpose and principlesWhat the treatment does and how it fits into care.
Common causes include peptic ulcer, oesophagitis, varices, portal hypertensive gastropathy, Mallory–Weiss tear, vascular lesions and upper-GI malignancy. Clinical history can suggest a cause—cirrhosis, NSAIDs, anticoagulants, retching or previous ulcer—but treatment begins before certainty. A patient can lose a large circulating volume before haemoglobin falls, and beta-blockade or pacing may blunt tachycardia.
Early care combines recognition, resuscitation, risk assessment, treatment, referral and review. Record observations frequently, assess perfusion and mental state, send FBC, U&E, LFT, clotting and group-and-save or crossmatch, and obtain blood gas with lactate when unwell. Balanced blood-component therapy follows the local major-haemorrhage protocol in uncontrolled loss; otherwise avoid liberal red-cell transfusion because it may worsen outcomes and portal pressures.
Endoscopy establishes cause and delivers haemostasis. Timing is based on stability after resuscitation rather than an arbitrary overnight delay. Afterward, management branches into high-dose acid suppression for treated non-variceal stigmata, portal-hypertension care after variceal bleeding, H. pylori eradication, modification of NSAIDs, and careful restart of antithrombotic therapy. The indication for aspirin or anticoagulation is as important as the bleeding lesion, so cessation and resumption decisions are multidisciplinary.
Key points
- Upper-GI bleeding can present with haematemesis, coffee-ground vomit, melaena or brisk haematochezia; haemodynamic state matters more than the apparent colour or volume.
- Calculate the Glasgow–Blatchford score at first assessment and the full Rockall score after endoscopy; a score is an adjunct and never overrides shock or active bleeding.
- Use a restrictive red-cell transfusion strategy in most haemodynamically stable patients, commonly considering transfusion below 70 g/L, while individualising for exsanguination and cardiovascular disease.
- NICE recommends immediate endoscopy after resuscitation for unstable severe bleeding and endoscopy within 24 hours for other admitted patients with upper-GI haemorrhage.
- Do not routinely give acid suppression before diagnostic endoscopy for suspected non-variceal bleeding under NICE guidance; give PPI after endoscopic evidence of recent haemorrhage.
- If variceal bleeding is suspected, start terlipressin and prophylactic antibiotic treatment at presentation unless contraindicated, then arrange urgent variceal haemostasis.
- For non-variceal haemostasis, adrenaline injection must not be used alone; combine an accepted mechanical or thermal method according to lesion and expertise.
- Rebleeding after initial endoscopic control needs prompt senior reassessment, repeat endoscopic therapy where appropriate and early interventional-radiology or surgical escalation if control fails.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Fresh or altered blood in vomit and black tarry stool are classic. Iron, bismuth and diet can darken stool, but true melaena is sticky, offensive and clinically interpreted with physiology and haemoglobin trend.
Cool peripheries, delayed capillary refill, confusion, oliguria, postural symptoms or rising lactate may precede hypotension. Older people and those taking rate-limiting medicines may not become tachycardic.
Known cirrhosis, portal hypertension, splenomegaly, ascites, thrombocytopenia or previous varices raises suspicion and should trigger pre-endoscopy vasoactive and antibiotic therapy while other sources remain possible.
Ongoing large-volume haematemesis, agitation, encephalopathy or reduced consciousness makes aspiration likely. Secure experienced anaesthetic assessment before sedated endoscopy rather than relying on suction alone.
Record the exact anticoagulant, last dose, renal function, antiplatelet indication, NSAIDs and corticosteroids. The trade-off between reversal and thrombosis differs for each agent and indication.
Severe chest or abdominal pain, subcutaneous emphysema or peritonism suggests perforation rather than uncomplicated luminal bleeding and needs urgent imaging and surgical input.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Serial observations and perfusion assessmentFirst step - Why
- Measure current physiological threat and response to resuscitation.
- Interpretation and limitations
- Trend pulse, blood pressure, respiratory rate, saturation, temperature, mental state, urine output and shock index. A transient response to fluid can mask continuing haemorrhage.
- 02
FBC, clotting and fibrinogen - Why
- Assess anaemia, platelets and haemostatic derangement while preparing blood support.
- Interpretation and limitations
- Early haemoglobin may underestimate loss. Platelet and coagulation results guide component or reversal decisions in active bleeding, but abnormalities in cirrhosis do not map simply to bleeding tendency.
- 03
U&E, LFT and blood gas - Why
- Find renal impairment, liver disease, metabolic stress and a resuscitation baseline.
- Interpretation and limitations
- Raised urea relative to creatinine supports a proximal source; lactate and base deficit reflect hypoperfusion but are not specific. Renal clearance affects direct oral anticoagulant persistence.
- 04
Group-and-save or crossmatch - Why
- Ensure appropriately matched blood is available according to bleeding severity.
- Interpretation and limitations
- Escalate to the major-haemorrhage pathway when loss is uncontrolled rather than ordering isolated units slowly. Check previous antibodies and communicate urgency to transfusion staff.
- 05
Glasgow–Blatchford score - Why
- Estimate need for hospital-based intervention before endoscopy.
- Interpretation and limitations
- Calculate at presentation after obtaining required data. NICE considers early discharge for a pre-endoscopy score of zero, but only with clinical judgement, reliable support and an appropriate follow-up plan.
- 06
Therapeutic upper-GI endoscopy - Why
- Identify the bleeding source and achieve endoscopic haemostasis.
- Interpretation and limitations
- Report lesion, stigmata, therapy and rebleeding plan. Active bleeding, a non-bleeding visible vessel or adherent clot changes treatment; varices require banding or cause-specific gastric-varix expertise.
- 07
CT angiography or catheter angiography - Why
- Localise and treat ongoing bleeding not controlled or reached endoscopically.
- Interpretation and limitations
- Interventional radiology can embolise an arterial source. A negative study during intermittent bleeding does not prove resolution; choice and timing belong to the bleeding MDT.
04Treatment approachPreparation, options, escalation and aftercare.
01ResuscitateRestore perfusion safelyFirst stepAny patient presents with suspected acute upper-GI bleeding and physiological or ongoing blood-loss concern.+
- 1Use ABCDE, monitor continuously when unstable, insert appropriate venous access, send urgent bloods and crossmatch, and summon senior endoscopy, anaesthetic and transfusion support early.
- 2Give crystalloid and blood components according to response and the local haemorrhage protocol, using restrictive red-cell thresholds only when the patient is sufficiently stable for concentration-based decisions.
- 3DefinitiveEscalationReview antithrombotics and comorbidity, calculate Glasgow–Blatchford score, and document escalation, airway and ceiling-of-care decisions while definitive haemostasis is organised.
02TreatMatch pre-endoscopy therapyInitial stabilisation is underway and variceal versus non-variceal probability can be estimated.+
- 1For suspected variceal haemorrhage, give terlipressin and prophylactic antibiotics promptly unless contraindicated, and involve a service capable of band ligation and rescue portal intervention.
- 2For suspected non-variceal bleeding, avoid routine pre-endoscopy PPI under NICE guidance, correct relevant coagulopathy proportionately and prepare for therapeutic rather than purely diagnostic endoscopy.
- 3Perform endoscopy immediately after resuscitation in unstable severe bleeding or within 24 hours in other admitted cases, using combined haemostatic methods rather than adrenaline injection alone.
03PreventReduce rebleeding and harmEndoscopic haemostasis has been achieved or the bleeding source has been defined.+
- 1Use post-endoscopy PPI for non-variceal lesions with stigmata according to the endoscopy protocol, test and eradicate H. pylori, and review NSAID or aspirin necessity.
- 2Plan portal-hypertension secondary prevention after variceal bleeding and specify when vasoactive and antibiotic courses stop; consider rescue or pre-emptive portal intervention only through specialist criteria.
- 3EscalationAgree antiplatelet and anticoagulant restart timing with the responsible specialists, monitor for rebleeding, and escalate recurrence to repeat endoscopy, embolisation or surgery without avoidable delay.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Terlipressin for suspected variceal bleeding
Using Glypressin 1 mg, administer 2 mg by intravenous injection every 4 hours initially. After the first dose, use 1 mg every 4 hours if body weight is below 50 kg or adverse effects occur. Treat until bleeding has remained controlled for 24 hours, capped at 48 hours by the current SmPC. NICE says to stop terlipressin after definitive haemostasis or within 5 days, but that pathway ceiling does not override a named product's shorter licensed maximum.Review coronary, peripheral or mesenteric ischaemia, arrhythmia, severe hypertension, pregnancy context, sodium and fluid balance. Stop and seek senior advice for chest pain, ischaemic signs, severe hyponatraemia or ineffective control.
Prophylactic antibiotic for suspected variceal haemorrhage
Start promptly using the local cirrhosis and antimicrobial guideline, with agent, route and duration selected for allergy, renal function, prior colonisation and regional resistance.Obtain cultures when infection is suspected without delaying treatment, review for Clostridioides difficile and resistant-organism risk, and stop or narrow at the protocol endpoint.
Post-endoscopy proton-pump inhibitor
Use the named intravenous or oral regimen in the local bleeding protocol after endoscopy demonstrates non-variceal stigmata of recent haemorrhage; step down according to lesion and rebleeding risk.NICE does not recommend routine acid suppression before endoscopy for suspected non-variceal bleeding. Reconcile route, renal and liver context, interactions and the later ulcer or H. pylori plan.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Record observations frequently until physiology and bleeding are stable, including mental state, capillary refill and urine output rather than pulse and blood pressure alone.
- Trend haemoglobin, platelets, coagulation, fibrinogen, lactate, renal function and electrolytes at a frequency matched to ongoing loss and transfusion.
- Audit timing of senior review, risk score, variceal treatment and endoscopy against the BSG care bundle and document any justified variance.
- Watch for recurrent haematemesis, melaena with shock, haemoglobin decline or rising urea after haemostasis and activate the agreed rebleeding route promptly.
- Before discharge, confirm cause-specific medication, H. pylori testing, antithrombotic restart, alcohol or liver care, follow-up endoscopy and a clear return plan.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Concentration follows volume
Haemoglobin can look normal before interstitial fluid or resuscitation dilutes circulating blood, so initial physiology outranks a reassuring number.
Red stool can be upper
Very brisk upper-GI haemorrhage may transit rapidly and present as haematochezia, particularly when accompanied by shock or a high urea.
Adrenaline needs a partner
Injection can slow bleeding and improve visualisation but should be combined with a definitive mechanical or thermal modality rather than used alone.
Cirrhosis changes the bundle
Suspected varices require vasoactive therapy and infection prophylaxis before endoscopy, even though the eventual source may prove non-variceal.
Stopping also causes harm
Withholding aspirin after coronary disease or anticoagulation after recent thrombosis carries real risk, making indication-specific restart planning part of bleeding care.
08Common pitfallsFrequent interpretation and management errors.
- 01
Waiting for haemoglobin to fall before recognising haemorrhagic shock.
- 02
Using a low risk score to override ongoing haematemesis or abnormal physiology.
- 03
Giving liberal red-cell transfusion to a stable patient without considering threshold and cardiovascular context.
- 04
Delaying terlipressin and antibiotic treatment until varices are visually confirmed in a high-probability presentation.
- 05
Using adrenaline injection as the only endoscopic treatment for a bleeding ulcer.
- 06
Stopping or restarting an anticoagulant without recording its indication, last dose, renal clearance and thrombosis risk.