Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Resuscitate acute upper gastrointestinal haemorrhage before diagnosis, risk-stratify consistently, initiate cause-specific pre-endoscopy treatment, deliver timely therapeutic endoscopy, and coordinate rebleeding, antithrombotic and secondary-prevention decisions.
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.
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.
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.
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.
Haemoglobin can look normal before interstitial fluid or resuscitation dilutes circulating blood, so initial physiology outranks a reassuring number.
Very brisk upper-GI haemorrhage may transit rapidly and present as haematochezia, particularly when accompanied by shock or a high urea.
Injection can slow bleeding and improve visualisation but should be combined with a definitive mechanical or thermal modality rather than used alone.
Suspected varices require vasoactive therapy and infection prophylaxis before endoscopy, even though the eventual source may prove non-variceal.
Withholding aspirin after coronary disease or anticoagulation after recent thrombosis carries real risk, making indication-specific restart planning part of bleeding care.
Waiting for haemoglobin to fall before recognising haemorrhagic shock.
Using a low risk score to override ongoing haematemesis or abnormal physiology.
Giving liberal red-cell transfusion to a stable patient without considering threshold and cardiovascular context.
Delaying terlipressin and antibiotic treatment until varices are visually confirmed in a high-probability presentation.
Using adrenaline injection as the only endoscopic treatment for a bleeding ulcer.
Stopping or restarting an anticoagulant without recording its indication, last dose, renal clearance and thrombosis risk.
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A man with known cirrhosis presents with haematemesis and hypotension. Resuscitation and urgent endoscopy are being arranged. Which additional treatment principle is correct?
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes
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.