Synopsis
Resuscitate acute upper-GI haemorrhage, protect the airway, use blood components proportionately, deliver endoscopy at the correct time and prevent rebleeding after endoscopic haemostasis.
- 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.
Key red flags
Reduced consciousness or continuing high-volume haematemesis requires early airway planning because emergency endoscopy cannot be performed safely through an unprotected contaminated airway.
Persistent hypotension, rising lactate or recurrent bleeding after initial haemostasis should prompt repeat endoscopy or urgent radiological or surgical control, not repeated crystalloid alone.
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.
Reasoning priorities
Measure immediate airway, respiratory and perfusion response.
A falling pressure or rising lactate despite fluid and blood suggests ongoing haemorrhage and need for faster control.
Worked reasoning
A 66-year-old has repeated red haematemesis, pulse 126, systolic pressure 82 mmHg and reduced peripheral perfusion while taking naproxen.
- Call 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.
- Under 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.
- Apply 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.
- Control 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.
A patient with melaena is normotensive after assessment and has no ongoing haematemesis but requires hospital admission.