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.
- 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.
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.
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.
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.
- Review antithrombotics and comorbidity, calculate Glasgow–Blatchford score, and document escalation, airway and ceiling-of-care decisions while definitive haemostasis is organised.