Acute Upper Gastrointestinal Bleeding

Key points

• Risk assessment: Blatchford score at first assessment · full Rockall score after endoscopy (NICE CG141) · Blatchford 0 → consider early discharge with outpatient follow-up.
• Blatchford components: urea · haemoglobin (sex-specific) · systolic BP · pulse ≥ 100 · melaena · syncope · hepatic disease · cardiac failure.
• Resuscitate: ABC with two wide-bore cannulae · transfuse red cells using a restrictive threshold (around 70 g/l, or 80 g/l with cardiovascular disease) unless there is massive haemorrhage — do not over-transfuse · platelets if actively bleeding with platelets < 50 × 10⁹/l · FFP if fibrinogen < 1 g/l or INR/APTT > 1.5× normal · prothrombin complex concentrate if on warfarin and actively bleeding.
• Do NOT offer acid-suppression drugs (PPIs or H2 receptor antagonists) BEFORE endoscopy to patients with suspected non-variceal upper GI bleeding — a classic exam point. Offer a PPI after endoscopy only if stigmata of recent haemorrhage were treated.
• Suspected VARICEAL bleeding: give terlipressin AND prophylactic broad-spectrum antibiotics at presentation, before endoscopy · band ligation for oesophageal varices · TIPS if bleeding is not controlled.
• Timing of endoscopy: immediately after resuscitation if unstable with severe bleeding · within 24 hours of admission for everyone else.

Decision points in this pathway

• Blatchford score 0?
• Suspected variceal bleeding (known liver disease, stigmata of chronic liver disease)?
• Haemodynamically unstable with severe bleeding?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.