01Principles and purposeThe professional or clinical skill and the decisions it supports.
Non-variceal upper-GI haemorrhage includes peptic ulcer, erosive disease, Mallory-Weiss tear, tumour, Dieulafoy lesion and vascular ectasia. Appearance of vomit alone does not determine severity. Coffee-ground material may accompany significant bleeding, and a brisk upper source can present with haematochezia. Risk assessment begins with airway, breathing, circulation and ongoing-loss assessment, not a calculator.
The Glasgow-Blatchford score is calculated before endoscopy and estimates whether transfusion, endoscopic treatment or another intervention is likely. Urea rises as digested blood is absorbed and renal perfusion falls. Haemoglobin thresholds differ by sex. Melaena, syncope, hepatic disease and cardiac failure add clinical risk. A true score of 0 is a narrow category and NICE permits consideration of early discharge only after broader clinical suitability is confirmed. ESGE 2026 identifies GBS 0–1 as very low risk suitable for outpatient management and endoscopy; that broader threshold must not be quoted as NICE’s score-zero wording. Ongoing bleeding, instability, another acute illness or an unsafe follow-up arrangement overrides a numerical discharge shortcut.
Rockall scoring serves a later stage. The pre-endoscopic portion uses age, shock and comorbidity; the full score requires endoscopic diagnosis and major stigmata of recent haemorrhage. Neither score replaces judgement about anticoagulation, social support, recurrent bleeding or another acute illness. A useful handover states current physiology, resuscitation, score with inputs, haemoglobin trend, antithrombotics and timing of endoscopy.
Calculate GBS by adding one value per category. Urea in mmol/L: below 6.5 = 0; 6.5–<8 = 2; 8–<10 = 3; 10–<25 = 4; at least 25 = 6. Male haemoglobin in g/L: at least 130 = 0; 120–<130 = 1; 100–<120 = 3; below 100 = 6. Female haemoglobin: at least 120 = 0; 100–<120 = 1; below 100 = 6. Systolic pressure in mmHg: at least 110 = 0; 100–109 = 1; 90–99 = 2; below 90 = 3. Add pulse at least 100/min = 1, melaena = 1, syncope = 2, hepatic disease = 2 and cardiac failure = 2; absent features add zero.
For full Rockall, sum five categories using the presentation physiology and subsequent endoscopic findings. Age: below 60 = 0, 60–79 = 1, at least 80 = 2. Shock: systolic pressure at least 100 with pulse below 100 = 0, pressure at least 100 with pulse at least 100 = 1, pressure below 100 = 2. Comorbidity: no major disease = 0; cardiac failure, ischaemic heart disease or another major comorbidity = 2; renal failure, liver failure or disseminated malignancy = 3. Diagnosis: Mallory-Weiss tear, or no identified lesion and no recent-bleeding stigmata = 0; other diagnoses = 1; upper-GI malignancy = 2. Major stigmata: none or a dark spot alone = 0; blood in the upper GI tract, adherent clot, visible or spurting vessel = 2. Use the highest applicable value within a category, not the sum of mutually exclusive alternatives.
Key points
- Use Glasgow-Blatchford before endoscopy and full Rockall afterwards. For a 68-year-old with presenting pressure 104 mmHg, pulse 108, no major comorbidity and a duodenal-ulcer visible vessel, full Rockall is age 1 + shock 1 + comorbidity 0 + diagnosis 1 + stigma 2 = 5.
- GBS combines urea, sex-specific haemoglobin, pressure, pulse and clinical features: melaena adds one point and syncope two; hepatic disease and cardiac failure each add two. Use exact thresholds rather than an estimated low score.
- NICE considers early discharge at GBS 0; ESGE 2026 identifies GBS 0–1 as very low risk for outpatient management. Both need a stable patient, no separate admission need and safe investigation, follow-up and return arrangements.
- The full Rockall score adds endoscopic diagnosis and stigmata to age, shock and comorbidity, refining mortality and rebleeding risk after the lesion is seen.
- Haemoglobin measures concentration and may appear normal early in major acute blood loss, so pulse, pressure, perfusion, mental state and bleeding trajectory remain essential.
- Record the inputs as well as the total; a copied score without urea units, sex-specific haemoglobin or comorbidity review cannot be audited safely.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Fresh red blood suggests active proximal bleeding, while coffee-ground material reflects haematin formation but does not guarantee low volume.
Black tarry offensive stool indicates digested blood and adds a point-bearing clinical feature to the Blatchford score.
Tachycardia, hypotension, cool peripheries, confusion and oliguria indicate reduced circulating volume and demand immediate treatment.
Normal initial haemoglobin can coexist with substantial acute loss before equilibration.
New haematemesis, melaena with circulatory change or a haemoglobin fall after initial control requires urgent reassessment.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Glasgow-Blatchford score - Why
- Estimate intervention need at first presentation before endoscopy.
- Interpretation and limitations
- Calculate from contemporaneous urea, sex-specific haemoglobin, systolic pressure, pulse and clinical features; NICE early-discharge consideration is score 0. Syncope scores two and melaena one; use the complete threshold table in the summary, rather than estimating low risk from normal blood pressure alone.
- 02
Full blood count - Why
- Measure anaemia, platelet count and serial change.
- Interpretation and limitations
- Do not infer low blood loss from one early haemoglobin; dilution and continued bleeding change the concentration.
- 03
Urea, creatinine and electrolytes - Why
- Supply a Blatchford variable and identify renal hypoperfusion.
- Interpretation and limitations
- Urea can rise from digested blood or dehydration, while creatinine helps distinguish baseline renal disease and acute injury.
- 04
Coagulation and group-and-save - Why
- Identify anticoagulant effect and prepare compatible blood if deterioration occurs.
- Interpretation and limitations
- Record the exact antithrombotic and last dose; correction depends on active bleeding severity and the drug involved.
- 05
Upper-GI endoscopy - Why
- Diagnose the source, identify stigmata and deliver haemostasis.
- Interpretation and limitations
- Full Rockall adds age, presentation shock and comorbidity to the diagnosis and major stigmata. For example, age 68 scores 1, systolic pressure 104 with pulse 108 scores 1, no major comorbidity scores 0, duodenal ulcer scores 1 and a non-bleeding visible vessel scores 2: total 5. Successful treatment does not erase the presenting stigma.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked case: verify a Blatchford score of zeroCalculate every component before dischargeA 31-year-old man has one small self-limited haematemesis after retching, pulse 82, systolic pressure 126 mmHg, urea 5.4 mmol/L and haemoglobin 146 g/L, with no melaena, syncope, liver disease or cardiac failure.+
- 1Confirm airway safety, stable serial observations, no ongoing bleeding, benign abdominal examination and no anticoagulant exposure before using a score to support disposition.
- 2Enter each value and clinical feature: all Glasgow-Blatchford components score zero, producing a documented total of 0 rather than an estimated low score.
- 3After senior review, consider early discharge under NICE guidance with an arranged follow-up investigation and explicit return instructions for recurrent blood, melaena, fainting or weakness.
- 4Verify next-day contact: there has been no further bleeding, oral fluids are tolerated and the booked endoscopy or clinic plan is visible to both patient and receiving service.
02High-risk presentationResuscitate before calculatingAn older patient has repeated red haematemesis, pulse 124 and systolic pressure 84 mmHg.+
- 1Call for senior, anaesthetic and endoscopy support and begin haemorrhage resuscitation immediately.
- 2Secure airway when consciousness or ongoing vomiting threatens aspiration and obtain urgent vascular access and blood products as indicated.
- 3Calculate and communicate the score once essential treatment is running, recognising that instability already mandates admission and urgent endoscopy.
- 4Reassess pressure, perfusion, lactate, urine output and ongoing blood loss after each intervention.
03Worked case: nonzero GBS and full RockallShow the calculation at both decision pointsA 68-year-old man presents with melaena and syncope, pulse 108/min, systolic pressure 104 mmHg, urea 12 mmol/L and haemoglobin 92 g/L. He has no major comorbidity, including no hepatic disease or cardiac failure. Endoscopy later finds a duodenal ulcer with a non-bleeding visible vessel.+
- 1Start assessment and resuscitation while calculating GBS: urea 4 + male haemoglobin 6 + pressure 1 + pulse 1 + melaena 1 + syncope 2 + hepatic disease 0 + cardiac failure 0 = 15. Admit and organise endoscopy; neither the NICE zero threshold nor the ESGE 0–1 outpatient category applies.
- 2After endoscopy, calculate full Rockall from the original physiology and observed lesion: age 1 + tachycardic shock category 1 + comorbidity 0 + ulcer diagnosis 1 + visible-vessel stigma 2 = 5. The endoscopist clips the vessel successfully, but that does not retrospectively remove its two stigma points.
- 3Give the post-ulcer-haemostasis PPI course and monitor observations and haemoglobin. Over the next 72 hours there is no fresh haematemesis, pressure remains above 110 mmHg and haemoglobin is stable without further transfusion; causal H pylori testing and medicine review are documented.
- 4The handover specifies that recurrent fresh blood, hypotension or a haemoglobin fall with clinical concern triggers renewed resuscitation and urgent endoscopy review. If repeat haemostasis fails, the team escalates to embolisation, with surgery if embolisation is unavailable or unsuccessful.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- Repeat pulse, blood pressure, mental state, peripheral perfusion and urine output during active assessment.
- Trend haemoglobin, platelets, urea, creatinine and coagulation according to bleeding severity.
- Record score components and calculation time so later deterioration is not obscured by an old total.
- After haemostasis, monitor fresh haematemesis, melaena frequency, haemoglobin fall and transfusion need for rebleeding.
- Confirm follow-up and return access before any low-risk discharge.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Two scores, two moments
Blatchford predicts intervention before endoscopy; the full Rockall incorporates what the endoscopist actually finds.
Zero is a strict category
Melaena contributes one Glasgow-Blatchford point; syncope contributes two. Either prevents a score of zero, but their values must not be treated as interchangeable.
Urea carries two signals
Digested protein and reduced renal perfusion can both raise urea during upper-GI bleeding.
Scores organise handover
A total becomes useful only when paired with current physiology, treatment received and evidence of continuing bleeding.
07Common pitfallsFrequent interpretation and management errors.
- 01
Waiting for the calculator while a hypotensive patient continues to vomit blood.
- 02
Using a stable early haemoglobin as proof that blood loss is small.
- 03
Calling a Blatchford score of 1 equivalent to the NICE score-zero discharge criterion.
- 04
Calculating a full Rockall score before endoscopic diagnosis and stigmata exist.