Upper GI bleed: workup and management
Upper GI bleeding (hematemesis, coffee-ground emesis or melena). Resuscitate, risk-stratify with Glasgow-Blatchford, decide early whether varices are likely, and arrange endoscopy within 24 h.
Working diagnosis
Adult · US guidelines
Draft · awaiting physician review
01Orient
What's new in the evidence
- AASLD 2024 portal hypertension guidance: pre-emptive TIPS within 72 hours (ideally 24) for Child-Pugh C 10–13, or Child-Pugh B >7 with active bleeding at endoscopy
- Do not give FFP or platelets to correct INR or platelet count before variceal endoscopy; transfuse to hemoglobin ~7 g/dL
- Ceftriaxone 1 g/day for up to 5 days in cirrhosis, stopping when bleeding is controlled and there is no infection; stop PPIs once a variceal source is confirmed
- HALT-IT (2020): tranexamic acid does not reduce death in GI bleeding and increases venous thrombosis
- Over-the-scope clips are an option as first-line endoscopic therapy for high-risk ulcers
Differential diagnoses
- Peptic ulcer disease
- Esophagogastric varices
- Mallory-Weiss tear
- Erosive esophagitis or gastritis
- Malignancy
- Dieulafoy lesion, angiodysplasia
- Aortoenteric fistula (prior aortic graft)
02Assess
Risk scores and decision tools
- Glasgow-Blatchford score (0–1: outpatient management)
- Rockall score after endoscopy
- Child-Pugh and MELD 3.0 in cirrhosis
- Forrest classification of ulcer stigmata
Key history questions
- Volume and color of blood; melena vs hematochezia
- NSAIDs, aspirin, anticoagulants, antiplatelets, SSRIs
- Alcohol use, known cirrhosis or liver disease
- Retching before hematemesis (Mallory-Weiss)
- Weight loss, dysphagia
- Prior ulcer or bleed, H. pylori
Examination findings
- Tachycardia, hypotension, postural drop
- Stigmata of chronic liver disease, ascites, encephalopathy
- Abdominal tenderness or peritonism (perforation)
- Digital rectal exam for melena
03Investigate
Initial investigations
- CBC (Hb may not fall initially), BMP (BUN rises), LFTs
- Coagulation (INR), type and crossmatch
- Lactate
- Glasgow-Blatchford score
Advanced investigations
- Upper endoscopy within 24 h; within 12 h if variceal bleed suspected
- CT angiography if unstable and endoscopy unavailable or unrevealing
- H. pylori testing on biopsy
04Treat
Immediate management
- Two large-bore IVs; crystalloid resuscitation
- Restrictive transfusion: Hb threshold 7 g/dL (8 g/dL with cardiovascular disease)
- IV PPI: pantoprazole 80 mg IV bolus, then 40 mg IV twice daily (or infusion per local protocol)
- Suspected varices: octreotide 50 mcg IV bolus then 50 mcg/h, plus ceftriaxone 1 g IV daily
- Hold anticoagulants and NSAIDs; consider reversal for life-threatening bleed
First-line treatment
- Endoscopic hemostasis for high-risk stigmata
- Erythromycin 250 mg IV 30-120 min before endoscopy to clear the stomach
- Variceal band ligation for esophageal varices
Second-line treatment
- Pre-emptive TIPS within 72 hours (ideally 24) for high-risk variceal bleeding (Child-Pugh C 10–13 or B >7 with active bleeding)
- Interventional radiology embolization for refractory ulcer bleeding
- Rescue TIPS for refractory variceal bleeding; balloon tamponade only as a bridge
- Start a nonselective beta-blocker once vasoactive drugs stop if no TIPS
Specialist referrals
- Gastroenterology for endoscopy
- ICU for hemodynamic instability or massive transfusion
- Interventional radiology or surgery if endoscopy fails
05Disposition
Admission criteria
- Glasgow-Blatchford score 2 or more
- Hemodynamic instability or ongoing bleeding
- Suspected varices or cirrhosis
- Need for transfusion
Safe discharge criteria
- Glasgow-Blatchford score 0-1 with outpatient endoscopy arranged
- Hemodynamically stable with stable Hb
Follow-up timing
- Repeat Hb within 1 week if discharged
- Endoscopic follow-up for gastric ulcers (exclude malignancy)
Patient instructions
- Avoid NSAIDs and alcohol
- Return immediately for black stool, vomiting blood, dizziness or fainting
Monitoring
- Serial Hb every 6-12 h initially
- Hourly vitals while actively bleeding
Clinical pearls and pitfalls
- Rising BUN-to-creatinine ratio supports an upper source
- Treat H. pylori when found and confirm eradication
- Restart anticoagulation once hemostasis is secure, usually within 7 days, after weighing thrombotic risk
RefGuidelines and landmark evidence
- GuidelineACG – Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding (2021)PubMed
- GuidelineAASLD – Practice Guidance on Portal Hypertension and Varices in Cirrhosis (2024)PubMed
- TrialRestrictive vs liberal transfusion in acute UGIB (Villanueva et al., 2013)PubMed
- TrialHALT-IT: tranexamic acid in GI bleeding (2020)PubMed
- TrialTiming of endoscopy for acute UGIB (Lau et al., 2020)PubMed
For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.