Upper GI bleed
Two big cannulas, bloods and cross-match, resuscitate, and decide early whether this could be a variceal bleed. Terlipressin and antibiotics for varices, endoscopy within 24 hours (12 for varices).
A 54-year-old man with hepatitis C has vomited about two cups of fresh blood. He is jaundiced and his belly is distended. Pulse 124, BP 88/56. Hb 7.1 g/dL, platelets 62,000/µL, INR 1.8.
What do you do in the next 30 minutes?
- Two wide-bore cannulas16G or larger, one in each arm.
- Bloods and cross-matchCBC, urea, creatinine, LFTs, INR, group and cross-match 2–4 units.
- ResuscitateCrystalloid while blood is coming. Blood early if shocked.
- Could this be varices?Liver disease, hepatitis B or C, jaundice, ascites, alcohol: start terlipressin and antibiotics now.
- Stop the culpritsNSAIDs, aspirin, clopidogrel, warfarin, DOACs. Reverse anticoagulation if bleeding is severe.
- Score itGlasgow-Blatchford score.
- Call the GI or endoscopy teamEndoscopy within 12 hours for suspected varices, within 24 hours for others, sooner if unstable.
- Nil by mouth, catheter if shockedHourly urine output.
- Shocked, or still vomiting blood
- Known liver disease, ascites or jaundice
- Melaena with low BP or fast pulse
- On warfarin, DOAC or antiplatelets
- Drowsy or confused
- Blatchford score above 0
- Variceal bleed
- Large bleeding ulcer
- Perforated ulcer
- Aorto-enteric fistula (previous aortic graft)
- Liver encephalopathy triggered by the bleed
| Transfuse | Hb below 7 g/dL, aim 7–9 g/dL (below 8 with heart disease). Do not over-transfuse in varices |
| Variceal bleed | Terlipressin and IV antibiotics before endoscopy. Doses in the variceal section |
| Platelets | Transfuse if below 50,000/µL and actively bleeding |
| Blatchford 0 | Low risk, may be suitable for outpatient endoscopy |
| Tranexamic acid | Not recommended for GI bleeding |
Check every dose against a current drug reference and your hospital protocol.
On this page
What it is and why it matters
An upper GI bleed comes from the oesophagus, stomach or duodenum. It shows as haematemesis (vomiting fresh red blood or "coffee grounds") and/or melaena (black, sticky, tar-like, foul-smelling stool). A very brisk upper bleed can also come out as red blood from below.
Common causes in Pakistan:
- Peptic ulcer, often from NSAIDs (diclofenac, ibuprofen, painkiller injections) and Helicobacter pylori.
- Oesophageal varices from cirrhosis, very commonly due to hepatitis B and C.
- Erosive gastritis or oesophagitis.
- Mallory-Weiss tear after repeated vomiting.
- Cancer of the stomach or oesophagus.
Is this a variceal bleed?
- Hepatitis B or C, alcohol, jaundice, ascites, big spleen, spider naevi
- Start terlipressin and IV antibiotics now, before endoscopy
- Endoscopy within 12 hours
- Ulcer, gastritis, tear, cancer
- Resuscitate, stop NSAIDs and antiplatelets
- Endoscopy within 24 hours (sooner if unstable)
History and examination
- How much blood, how many times, fresh or coffee grounds. Black stools.
- Dizziness or fainting (significant blood loss).
- Medicines: NSAIDs, painkiller injections, aspirin, clopidogrel, warfarin, DOACs, steroids.
- Liver disease, hepatitis B or C, alcohol, previous varices or banding.
- Previous ulcers, weight loss, difficulty swallowing (cancer).
- Previous aortic surgery (aorto-enteric fistula).
- Examine: pulse, BP, postural drop, capillary refill, GCS. Signs of chronic liver disease. Rectal examination for melaena.
Glasgow-Blatchford score
| Feature | Points |
|---|---|
| Urea 6.5–8 mmol/L (39–48 mg/dL) | 2 |
| Urea 8–10 mmol/L (48–60 mg/dL) | 3 |
| Urea 10–25 mmol/L (60–150 mg/dL) | 4 |
| Urea above 25 mmol/L (above 150 mg/dL) | 6 |
| Hb (men) 12–13 g/dL | 1 |
| Hb (men) 10–12 g/dL | 3 |
| Hb (women) 10–12 g/dL | 1 |
| Hb below 10 g/dL (men or women) | 6 |
| Systolic BP 100–109 | 1 |
| Systolic BP 90–99 | 2 |
| Systolic BP below 90 | 3 |
| Pulse 100 or more | 1 |
| Melaena | 1 |
| Fainting (syncope) | 2 |
| Liver disease | 2 |
| Heart failure | 2 |
A score of 0 means low risk: the patient may be suitable for discharge with early outpatient endoscopy. Any higher score needs admission and inpatient endoscopy. A rising urea with a normal creatinine is a sign of blood in the gut.
Resuscitation and blood
- Two large cannulas16G or bigger.
- CrystalloidIf shocked, while blood is coming.
- BloodIf shocked or Hb below 7 g/dL. Activate the major haemorrhage protocol if bleeding is massive.
- TargetsHb 7–9 g/dL (8 or more with heart disease). In varices, avoid over-transfusion: it raises portal pressure and can restart bleeding.
- ClottingPlatelets if below 50,000/µL and actively bleeding. FFP if INR or APTT more than 1.5 times normal and actively bleeding.
- MonitorPulse, BP, urine output hourly. Repeat Hb.
Variceal bleeding
- Endoscopy within 12 hours: band ligation for oesophageal varices.
- Uncontrolled bleeding: a balloon tube (Sengstaken-Blakemore or Minnesota) can be placed by an experienced senior as a bridge to definitive treatment.
- After the bleed: beta-blocker (propranolol or carvedilol) and a banding programme to prevent the next one.
Non-variceal bleeding (ulcers)
- Endoscopy within 24 hours, sooner if unstable.
- PPI: many hospitals give IV omeprazole or esomeprazole while waiting for endoscopy. This is reasonable if endoscopy is delayed, but it must never delay the endoscopy. After endoscopic treatment of a high-risk ulcer, high-dose PPI is essential.
- Stop NSAIDs. Test and treat H. pylori.
- Aspirin for heart disease: usually restarted once bleeding is controlled. Discuss with your senior: stopping it permanently raises the risk of heart attack and stroke.
- Rebleeding or failed endoscopy: repeat endoscopy, interventional radiology, or surgery.
Tranexamic acid is not recommended for GI bleeding. The large HALT-IT trial showed no reduction in deaths and more clots (DVT, PE) with it.
Reversing blood thinners
- Warfarin with severe bleeding: vitamin K 5–10 mg IV plus prothrombin complex concentrate (or FFP if PCC is not available).
- DOACs: senior advice. Specific reversal agents if available, otherwise PCC.
- Antiplatelets: stop clopidogrel. Platelet transfusion only in life-threatening bleeding after senior discussion.
Common mistakes
- Waiting for the endoscopy to start terlipressin and antibiotics in a patient with liver disease.
- Transfusing a variceal bleed to a "normal" Hb of 12.
- Giving tranexamic acid.
- Forgetting the rectal examination for melaena.
- Missing the painkiller injections and over-the-counter NSAIDs in the history.
- Stopping aspirin permanently in a patient with recent heart stents without discussion.
Frequently asked questions
What is the dose of terlipressin in variceal bleeding?
2 mg IV every 4 hours until bleeding is controlled, then 1 mg every 4 hours, usually for 2–5 days according to local protocol.
When should blood be transfused in an upper GI bleed?
When Hb is below 7 g/dL, aiming for 7–9 g/dL (a threshold of 8 in patients with heart disease), or earlier if the patient is shocked with major bleeding.
Why are antibiotics given in variceal bleeding?
Patients with cirrhosis who bleed are at high risk of infection. Antibiotics such as ceftriaxone reduce infection, rebleeding and death.
Is tranexamic acid used in upper GI bleeding?
No. The HALT-IT trial showed it did not reduce deaths and increased the risk of blood clots.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A man with hepatitis C cirrhosis and ascites is vomiting blood. BP 88/56. Which two drugs should be given before endoscopy?
Answer: Terlipressin and ceftriaxone. Suspected variceal bleeding: resuscitate, terlipressin (2 mg IV 4-hourly), prophylactic antibiotics (for example ceftriaxone 1 g daily), restrictive transfusion and endoscopy within 12 hours.
- Omeprazole and tranexamic acid: Tranexamic acid is not recommended; terlipressin and antibiotics are key in variceal bleeding.
- Propranolol and omeprazole: Beta-blockers are not given in an acute bleed with hypotension.
- Furosemide and spironolactone: Diuretics are stopped in an acute bleed.
- Octreotide and vitamin K only: Vitamin K doesn't reverse cirrhotic coagulopathy meaningfully.
2. A cirrhotic patient with a variceal bleed has had 3 units of blood. Haemoglobin is now 9.6 g/dL and he is stable. What is the best transfusion plan?
Answer: No further blood for now; target 7–9 g/dL. A restrictive transfusion strategy (Hb target 7–8, up to 9 g/dL) improves survival in upper GI bleeding, especially variceal.
- Transfuse to 12 g/dL: Over-transfusion raises portal pressure and rebleeding.
- Transfuse 2 more units routinely: Not needed while stable.
- FFP to correct INR before endoscopy: Not routinely recommended.
- Platelets regardless of count: Only if very low and bleeding.
3. A colleague suggests tranexamic acid for an adult with upper GI bleeding. What is the best response?
Answer: Not recommended. The HALT-IT trial found no reduction in death and an increase in venous thrombosis with tranexamic acid in GI bleeding.
- Give only for variceal bleeds: Not recommended in either.
- Give with omeprazole for synergy: No evidence.
- It reduces mortality and should be given to all: HALT-IT showed no mortality benefit.
- Give orally rather than IV: Route doesn't change the evidence.
4. A 30-year-old with one episode of small-volume haematemesis after vomiting has HR 78, BP 128/80, Hb 145 g/L and urea normal. Glasgow–Blatchford score is 0. What is appropriate?
Answer: Outpatient management. The Glasgow–Blatchford score (urea, Hb, systolic BP, pulse, melaena, syncope, liver disease, heart failure) predicts the need for intervention in upper GI bleeding. A score of 0–1 identifies very low-risk patients who can be managed as outpatients with early endoscopy. Higher scores need admission, resuscitation and endoscopy within 24 hours. A Mallory–Weiss tear after vomiting usually stops spontaneously.
- Emergency endoscopy tonight: A Blatchford score of 0 is very low risk and does not need emergency endoscopy.
- Two units of blood: He is not anaemic, so transfusion is not needed.
- IV terlipressin: Terlipressin is for variceal bleeding.
5. A man with cirrhosis has large oesophageal varices on screening endoscopy but has never bled. What reduces the risk of a first bleed?
Answer: Carvedilol. Primary prophylaxis for medium/large varices: non-selective β-blockers (carvedilol preferred, or propranolol) titrated to heart rate/BP, or endoscopic band ligation if β-blockers are contraindicated/not tolerated. Acute variceal bleed: resuscitation, terlipressin, prophylactic antibiotics (ceftriaxone), urgent band ligation within 12 h; TIPS for refractory bleeding. Secondary prophylaxis: β-blocker + band ligation.
- Long-term PPI: PPIs do not prevent variceal bleeding.
- Isosorbide mononitrate alone: Nitrates alone are not recommended.
- TIPS: TIPS is for refractory bleeding or ascites.
6. Octreotide is used for bleeding oesophageal varices and high-output pancreatic fistula because it:
Answer: Lowers splanchnic flow and secretion. Octreotide is a long-acting somatostatin analogue. It inhibits many gut hormones and secretions (gastrin, insulin, glucagon, pancreatic enzymes, growth hormone) and reduces splanchnic blood flow and portal pressure. Uses: variceal bleeding, fistulas, acromegaly, carcinoid and VIPoma.
- Increases gastric acid secretion: It reduces acid.
- Stimulates pancreatic enzymes: It reduces pancreatic secretion.
- Raises portal venous pressure: It lowers portal pressure.
- Acts as a proton pump inhibitor: Different mechanism.
7. Where is the most common site of a benign gastric ulcer?
Answer: Lesser curvature at the incisura. Gastric ulcers most often occur on the lesser curvature at the incisura angularis, at the junction of acid-secreting body and antral mucosa. Duodenal ulcers are commoner overall and occur in the first part of the duodenum: anterior ulcers perforate; posterior ulcers bleed from the gastroduodenal artery. Greater curvature ulcers are suspicious for malignancy and must be biopsied.
- Greater curvature of the fundus: Uncommon; raises suspicion of cancer.
- First part of duodenum, posterior: Commonest duodenal site, not gastric.
- Cardia: Less common.
- Pyloric canal, greater curve: Not the commonest.
References and dose sources
- NICE CG141: Acute upper gastrointestinal bleeding in over 16s
- HALT-IT trial: tranexamic acid in GI bleeding (Lancet 2020)
- Baveno VII consensus on portal hypertension
- BSG — guidance on variceal haemorrhage
- Terlipressin dosing: Drugs.com: Terlipressin dosage (see also our terlipressin dose page)
- Ceftriaxone dosing: Drugs.com: Ceftriaxone dosage (see also our ceftriaxone dose page)
- Lactulose dosing: Drugs.com: Lactulose dosage (see also our lactulose dose page)
- Omeprazole dosing: Drugs.com: Omeprazole dosage (see also our omeprazole dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.