01Principles and purposeThe professional or clinical skill and the decisions it supports.
Resuscitation and haemostasis proceed together. Airway risk rises with active vomiting, agitation, encephalopathy and aspiration. Circulation assessment integrates pressure, pulse, capillary refill, mental state, urine output and lactate. Crystalloid can restore perfusion temporarily but excessive dilution worsens coagulation and obscures continuing loss. Blood-component decisions use the clinical picture, not haemoglobin alone.
Timing language matters. NICE recommends immediate endoscopy after optimal resuscitation for unstable severe bleeding; its quality standard operationalises this as within two hours of optimal resuscitation. Other admitted patients should undergo endoscopy within 24 hours of admission. ESGE 2026 generally recommends endoscopy within 24 hours and reserves emergent or urgent examination for continuing haemodynamic instability despite adequate resuscitation. NICE advises against pre-endoscopy acid suppression for suspected non-variceal bleeding; ESGE 2026 instead suggests considering high-dose IV PPI before endoscopy, without delaying it. These are distinct recommendations, not one combined mandatory protocol.
Post-haemostasis care prevents failure. High-dose PPI stabilises clot over an ulcer after therapeutic endoscopy. H pylori is tested and eradicated; non-aspirin NSAIDs are stopped during the acute phase. Continued secondary-prevention aspirin is considered after haemostasis under NICE, while other antithrombotics require indication-specific specialist discussion. Recurrent haematemesis or shock triggers repeat endoscopy and, if control fails, interventional radiology or surgery.
For peptic ulcers, Forrest Ia is spurting and Ib oozing: deliver endoscopic haemostasis, commonly adrenaline plus a mechanical or thermal method; ESGE 2026 also supports selected over-the-scope clip monotherapy. Forrest IIa is a non-bleeding visible vessel and receives mechanical, thermal or sclerosant treatment, with or without adrenaline. Forrest IIb is an adherent clot: ESGE 2026 suggests clot removal and treatment of the underlying stigma when the endoscopist can safely manage provoked bleeding. Forrest IIc is a flat pigmented spot and III a clean base: neither needs endoscopic haemostasis; use appropriate ulcer medical treatment and assess suitability for early discharge. Never use adrenaline injection alone. These vessel and clot rules apply to peptic ulcers; current Mallory-Weiss guidance makes a different recommendation for a non-bleeding vessel in a tear.
Key points
- Begin with ABCDE, suction, two large-bore intravenous lines, full blood count, coagulation, renal profile, lactate and group-and-save or crossmatch according to severity.
- Use the local massive-haemorrhage protocol for massive bleeding; outside major haemorrhage or acute coronary syndrome, NICE supports a restrictive red-cell threshold of 70 g/L with a 70–90 g/L target.
- NICE: unstable severe bleeding needs immediate endoscopy after optimal resuscitation, other admissions within 24 hours, and no pre-endoscopy acid suppression. ESGE 2026: generally endoscopy within 24 hours unless instability persists despite adequate resuscitation, and consider pre-endoscopy high-dose IV PPI without delaying the procedure.
- After ulcer haemostasis, address the cause: test for H pylori, repeat an initially negative test under valid medication conditions when needed, stop non-aspirin NSAIDs during the acute bleed, and reconcile the indication and restart plan for antithrombotics.
- Ulcer Forrest Ia/Ib and IIa need endotherapy; IIb clot removal and underlying treatment requires suitable expertise. IIc flat spot and III clean base need no endoscopic haemostasis. Do not use adrenaline alone.
- After ulcer endotherapy, give esomeprazole 80 mg IV over 30 minutes then 8 mg/hour for 71.5 hours, completing 72 hours, followed by oral Nexium 40 mg once daily for four weeks in an adult without severe hepatic impairment; use the product-specific hepatic limits in prescribing.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Ongoing haematemesis, impaired consciousness or hypoxaemia predicts aspiration and difficult emergency endoscopy.
Hypotension, tachycardia, cool peripheries, confusion, oliguria and rising lactate indicate inadequate tissue perfusion.
In a peptic ulcer, spurting, oozing or a non-bleeding visible vessel needs endoscopic haemostasis; a flat pigmented spot or clean base does not. The ulcer classification must not be transferred automatically to a Mallory-Weiss tear.
Haemoglobin can fall after crystalloid and plasma refill even when no new bleeding occurs, requiring interpretation with physiology.
Fresh haematemesis, renewed circulatory instability or a significant haemoglobin fall after 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
Serial ABCDE and venous lactate - Why
- Measure immediate airway, respiratory and perfusion response.
- Interpretation and limitations
- A falling pressure or rising lactate despite fluid and blood suggests ongoing haemorrhage and need for faster control.
- 02
Full blood count and coagulation - Why
- Guide red cells, platelets and correction of clinically relevant coagulopathy.
- Interpretation and limitations
- Use trends and active bleeding; NICE offers platelets during active bleeding when count is below 50 × 10^9/L.
- 03
Group-and-save or crossmatch - Why
- Prepare compatible blood according to expected ongoing loss.
- Interpretation and limitations
- Massive bleeding requires protocolled balanced component support rather than isolated delayed requests.
- 04
Upper-GI endoscopy - Why
- Identify the source and deliver endoscopic haemostasis.
- Interpretation and limitations
- Document lesion, Forrest stigma, therapy, technical success and the plan if bleeding recurs.
- 05
CT angiography or catheter angiography - Why
- Localise and embolise bleeding when endoscopic control fails or is not feasible.
- Interpretation and limitations
- Coordinate with interventional radiology early because transfer and arterial anatomy affect rescue time.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked case: shock to durable haemostasisResuscitate, treat and verify controlA 66-year-old has repeated red haematemesis, pulse 126, systolic pressure 82 mmHg and reduced peripheral perfusion while taking naproxen.+
- 1Call anaesthetic, gastroenterology and transfusion support, use suction and airway positioning, obtain two large-bore lines and start protocolled haemorrhage resuscitation; pressure improves to 108 mmHg and mental state normalises.
- 2Under the NICE unstable-bleeding pathway, perform endoscopy within two hours of optimal resuscitation: a posterior duodenal ulcer has a Forrest IIa non-bleeding visible vessel, so treatment is indicated. The ulcer action map is Ia/Ib active bleeding and IIa vessel: haemostasis; IIb adherent clot: expert clot removal and underlying treatment; IIc flat spot or III clean base: no haemostatic endotherapy.
- 3Apply a mechanical clip to the ulcer vessel and confirm that haemostasis is achieved; a non-bleeding vessel does not require injection, clipping and thermal treatment all together. Start esomeprazole 80 mg IV over 30 minutes followed immediately by 8 mg/hour for 71.5 hours, with renal, hepatic and interaction checks.
- 4Control persists through 72 hours: there is no fresh haematemesis, pulse stays below 90 and haemoglobin stabilises without further transfusion. With normal hepatic function and a reliable oral route, change to Nexium 40 mg orally once daily for four weeks, swallowed whole with water. The H pylori and NSAID prevention plans and a rebleeding contact route are documented before discharge.
02Stable admitted bleedMeet the 24-hour windowA patient with melaena is normotensive after assessment and has no ongoing haematemesis but requires hospital admission.+
- 1Calculate Glasgow-Blatchford score, establish venous access and trend observations and haemoglobin.
- 2Arrange upper-GI endoscopy within 24 hours rather than waiting for weekday routine availability.
- 3Use the observed Forrest class to decide treatment: Ia/Ib active bleeding and IIa visible vessel receive haemostasis; IIb requires expertise for clot removal and underlying treatment; IIc/III need no endotherapy. Complete full Rockall after the findings are available.
- 4Define the observation, PPI and rebleeding pathway from the endoscopic stigma.
03Rebleeding after treatmentEscalate beyond the first techniqueFresh haematemesis and hypotension recur overnight after technically successful ulcer haemostasis.+
- 1Restart ABCDE resuscitation and inform endoscopy, anaesthesia, interventional radiology and surgery.
- 2Repeat endoscopy with further haemostatic treatment when feasible under NICE guidance.
- 3For recurrent ulcer bleeding, attempt further endoscopic haemostasis, considering an over-the-scope clip. If that second attempt fails, arrange transcatheter arterial embolisation; proceed to surgery when embolisation is unavailable or unsuccessful. Persistent uncontrolled bleeding despite the available endoscopic methods also needs prompt embolisation or surgical rescue.
- 4Verify perfusion, haemoglobin stability and absence of further bleeding after rescue.
05Relevant medicines and safetySpecific regimens and precautions when the skill involves prescribing.
Esomeprazole after therapeutic endoscopy for bleeding ulcer
After therapeutic endoscopy for acute bleeding from a gastric or duodenal ulcer, infuse esomeprazole 80 mg IV over 30 minutes, then 8 mg/hour IV continuously for 71.5 hours: 72 hours total. Follow with oral Nexium 40 mg once daily for four weeks, using its separate gastro-resistant tablet licence for prolonged treatment after IV prevention of ulcer rebleeding. Swallow the tablet whole with liquid; do not chew or crush it. The IV label requires oral follow-on treatment, while the oral label supplies this dose and duration.Do not delay resuscitation or endoscopic haemostasis. In severe hepatic impairment, after the initial 80 mg IV, 4 mg/hour for 71.5 hours may be sufficient; oral Nexium must not exceed 20 mg daily, requiring the appropriate lower-strength product rather than the 40 mg tablet. Renal impairment needs no dose adjustment, but severe renal insufficiency warrants caution. Contraindications include benzimidazole/product hypersensitivity and concomitant nelfinavir. Concomitant clopidogrel is discouraged; review interacting medicines, including high-dose methotrexate. Longer use warrants magnesium and B12 risk review. Continuing bleeding requires renewed source control, not escalation of PPI alone.
06Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- Repeat airway, respiratory and circulation observations continuously during active haemorrhage and sedation.
- Trend haemoglobin, lactate, urine output, coagulation and transfusion requirement with the clinical course.
- Document endoscopy time from optimal resuscitation and the lesion-specific haemostatic method.
- Watch for fresh blood, haemodynamic change and haemoglobin fall during the high-risk 72-hour period.
- Confirm H pylori, NSAID, antithrombotic and oral PPI plans before discharge.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Resuscitation enables endoscopy
The procedure becomes safer and more effective after airway and perfusion are stabilised, but resuscitation must remain brisk and goal-directed.
Adrenaline is an adjunct
Injection can slow bleeding and improve visualisation, but a second mechanical or thermal method provides more durable control.
Thresholds need exclusions
The 70 g/L restrictive red-cell threshold does not apply unchanged to major haemorrhage or acute coronary syndrome.
Rebleeding is a new emergency
Prior clipping does not make renewed hypotension benign; source control must be reconsidered immediately.
08Common pitfallsFrequent interpretation and management errors.
- 01
Intubating late after blood has repeatedly contaminated the airway.
- 02
Delaying unstable-patient endoscopy for complete correction of every laboratory value.
- 03
Using adrenaline injection alone for an actively bleeding peptic ulcer.
- 04
Treating recurrent shock with crystalloid while delaying repeat endoscopy or embolisation.