Synopsis
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.
- 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.
Key red flags
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.
Investigation priorities
Measure current physiological threat and response to resuscitation.
Management branches
Any patient presents with suspected acute upper-GI bleeding and physiological or ongoing blood-loss concern.
- Use ABCDE, monitor continuously when unstable, insert appropriate venous access, send urgent bloods and crossmatch, and summon senior endoscopy, anaesthetic and transfusion support early.
- Give 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.
Key medicines
Terlipressin for suspected variceal bleedingUsing 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.
Prophylactic antibiotic for suspected variceal haemorrhageStart promptly using the local cirrhosis and antimicrobial guideline, with agent, route and duration selected for allergy, renal function, prior colonisation and regional resistance.