Synopsis
Recognise upper gastrointestinal haemorrhage, resuscitate according to physiology, apply validated risk assessment, and coordinate time-critical endoscopic and variceal treatment with safe antithrombotic and transfusion decisions.
- Assess circulation and airway before debating ulcer versus varix; massive haematemesis and encephalopathy create a high aspiration risk that may require anaesthetic airway control.
- Two large-bore venous cannulae, blood count, renal and liver profiles, coagulation, group-and-save or crossmatch, lactate and frequent observations support resuscitation, but haemoglobin may initially appear normal.
- Use the Glasgow-Blatchford score at first assessment and the full Rockall score after endoscopy; a score supports disposition but never overrides active shock or clinical concern.
- Transfuse according to the overall clinical picture and current restrictive strategy, individualising for exsanguination, ischaemic heart disease and active instability rather than chasing a normal haemoglobin.
- Unstable severe bleeding needs endoscopy immediately after resuscitation; other admitted upper GI bleeds should undergo endoscopy within 24 hours under NICE guidance.
- Suspected variceal bleeding requires terlipressin and prophylactic antimicrobial therapy at presentation, with urgent endoscopic band ligation and early specialist discussion of rescue or pre-emptive TIPSS.
- Do not give acid suppression before endoscopy routinely for suspected non-variceal bleeding under NICE; after endoscopic stigmata and haemostasis, use the recommended PPI regimen.
- Review anticoagulants and antiplatelets immediately, balancing haemostasis against thrombotic indication with haematology, cardiology and endoscopy input; reversal is context specific.
- Endoscopic haemostasis requires combination or mechanical/thermal therapy appropriate to the lesion, followed by monitoring for rebleeding and radiological or surgical rescue when necessary.
Key red flags
Tachycardia, hypotension, narrow pulse pressure, cool peripheries, oliguria, altered mentation or raised lactate indicates inadequate perfusion. Beta-blockers and pacing can blunt tachycardia, so trends and end-organ signs matter.
Known cirrhosis, portal hypertension, previous varices, ascites, splenomegaly or thrombocytopenia with significant upper bleeding raises varices. Assume and treat early because infection and rebleeding risks are high.
A herald bleed followed by massive haemorrhage in a patient with previous aortic graft or aneurysm is a vascular catastrophe. Immediate vascular surgery and appropriate CT angiography take priority over routine endoscopy sequencing.
New haematemesis or melaena with pulse rise, hypotension, falling haemoglobin or increasing urea after initial control suggests recurrence and needs repeat resuscitation and urgent endoscopy or radiological rescue.
Investigation priorities
Quantify perfusion, airway risk and response to resuscitation before and after haemostasis.
Management branches
Haematemesis, coffee-ground vomit or melaena is reported or observed.
- Begin ABCDE, assess aspiration and encephalopathy, obtain two adequate venous lines, monitor continuously and send urgent crossmatch and organ profiles.
- Give warmed blood and fluids according to physiology and the local haemorrhage protocol, correcting hypothermia and major metabolic disturbance without over-resuscitating portal hypertension.
- Calculate Glasgow-Blatchford score while contacting the endoscopy team, but base level of care and timing on active bleeding, comorbidity and response.
- Review NSAIDs, antiplatelets and anticoagulants immediately and obtain specialist advice for reversal and later restart.