Summary

Acute upper gastrointestinal bleeding is a medical emergency where bleeding occurs from the esophagus, stomach, or first part of the small intestine (duodenum). Picture your digestive tract as a series of pipes—when one springs a leak, blood can pour out rapidly, causing you to lose significant amounts of blood in a short time. Patients may vomit bright red blood (hematemesis) or pass black, tarry stools (melena) that look like tar and smell foul. This condition affects approximately 100-200 per 100,000 people annually and carries a mortality of 5-10% overall, rising to 30-40% in high-risk patients. The key to survival is rapid assessment, aggressive resuscitation, risk stratification using validated scores (like the Glasgow-Blatchford or Rockall scores), and urgent endoscopy to identify and treat the bleeding source. Most bleeds stop spontaneously, but those that don't require endoscopic, radiological, or surgical intervention.

Key Facts

• Definition: Bleeding from GI tract proximal to ligament of Treitz (duodenal-jejunal junction)
• Incidence: 100-200 per 100,000/year; ~50,000-100,000 hospitalizations/year (UK)
• Mortality: 5-10% overall; 30-40% in high-risk patients
• Time to endoscopy: Urgent (<24h) for high-risk, routine for low-risk
• Critical threshold: Hemoglobin drop >2g/dL or need for >2 units blood
• Key investigation: Urgent upper GI endoscopy (OGD)
• First-line treatment: IV access, fluid resuscitation, PPI (omeprazole 80mg IV), urgent endoscopy

Clinical Pearls

"Hematemesis = Upper GI bleed" — Vomiting blood always indicates upper GI bleeding (above ligament of Treitz). Bright red = active bleeding; coffee-ground = old blood. Melena (black stools) also indicates upper GI source (blood takes time to turn black as it passes through).

"Resuscitate first, investigate second" — Don't delay resuscitation for endoscopy. Get IV access, start fluids, check bloods, then scope. A dead patient can't be scoped.

"Rockall score predicts mortality, Glasgow-Blatchford predicts need for intervention" — Use Rockall for prognosis, GBS for deciding who needs urgent endoscopy and admission.

"Most peptic ulcers stop bleeding on their own" — 80% stop spontaneously. Endoscopy is for the 20% that don't—identify high-risk stigmata (active bleeding, visible vessel) and treat endoscopically.

Why This Matters Clinically

Acute upper GI bleeding is a common emergency with significant mortality if not managed promptly. Rapid blood loss can lead to hypovolaemic shock and death within hours. The key is early recognition, aggressive resuscitation, and risk stratification to identify those needing urgent endoscopy versus those who can be managed conservatively. Delayed recognition or inappropriate management (like giving NSAIDs to someone with a bleeding ulcer) can be fatal. Protocol-driven management focusing on resuscitation, risk assessment, and timely endoscopy can reduce mortality significantly.

Structured Approach: ABCDE

A - Airway

• Assessment: Usually patent
• Finding: May have blood in mouth if recent hematemesis
• Action: Clear airway if needed

B - Breathing

• Look: Respiratory rate, use of accessory muscles
• Listen: Usually normal (unless severe anemia)
• Measure: SpO2 (usually normal unless severe)
• Action: Oxygen if hypoxic or severe anemia

C - Circulation

• Look: Skin colour (pale), capillary refill
• Feel: Pulse (rate, volume), BP (lying and standing)
• Listen: Heart sounds (tachycardia)
• Measure: BP (both arms), HR, ECG
• Action: IV access x2 (large bore), fluid resuscitation

D - Disability

• Assessment: GCS, mental status
• Finding: May be confused if hypovolaemic or liver disease
• Action: Check glucose; consider if hypovolaemia causing confusion

E - Exposure

• Look: Full body examination, look for stigmata of liver disease
• Feel: Abdomen (tenderness, masses)
• Action: PR examination (check for melena)

Specific Examination Findings

Cardiovascular Assessment:

Postural Blood Pressure:

• Technique: Measure BP lying, then standing
• Finding: Drop >20mmHg systolic = significant volume loss
• Significance: Indicates need for fluid resuscitation

Pulse Assessment:

• Rate: Tachycardia (compensatory)
• Volume: Weak if significant blood loss
• Rhythm: Usually regular (may be irregular if AF)

Abdominal Examination:

• Inspection: Distension (if ascites), scars (previous surgery)
• Palpation: Epigastric tenderness (ulcer), hepatosplenomegaly (liver disease)
• Auscultation: Usually normal bowel sounds

Rectal Examination:

• Purpose: Confirm melena, assess for lower GI bleeding
• Finding: Black, tarry stool = melena (upper GI)
• Note: Always do PR in GI bleeding

Special Tests

Natural History (Without Treatment)

Untreated Upper GI Bleeding:

• Mortality: 30-40% if massive, untreated
• Progression: Continued bleeding → hypovolaemic shock → death
• Time course: Death within hours if massive bleeding untreated

Outcomes with Treatment

Factors Affecting Outcomes:

Good Prognosis:

• Low Rockall score (0-2)
• Low GBS (0-2)
• Mallory-Weiss tear (usually self-limited)
• Young, healthy patient
• No comorbidities
• Successful endoscopic therapy

Poor Prognosis:

• High Rockall score (≥6)
• High GBS (≥6)
• Variceal bleeding (higher mortality)
• Malignancy (bleeding from tumor)
• Elderly, multiple comorbidities
• Failed endoscopic therapy
• Rebleeding

Prognostic Factors

Key Guidelines

1. NICE Guidelines (2012) — UK guidelines for acute upper GI bleeding. National Institute for Health and Care Excellence

Key Recommendations:

• Risk stratify using GBS
• Urgent endoscopy for high-risk (GBS ≥3)
• PPI before and after endoscopy
• Endoscopic therapy for high-risk stigmata
• Evidence Level: 1A

2. International Consensus (2019) — International guidelines for non-variceal upper GI bleeding. Gastroenterology

Key Recommendations:

• Resuscitate before endoscopy
• Urgent endoscopy (<24h) for high-risk
• Combination endoscopic therapy
• High-dose PPI after endoscopy
• Evidence Level: 1A

3. Baveno VII Consensus (2022) — Guidelines for variceal bleeding. Journal of Hepatology

Key Recommendations:

• Antibiotic prophylaxis (reduces mortality)
• Band ligation for esophageal varices
• TIPS for refractory bleeding
• Evidence Level: 1A

Landmark Trials

Lau et al. (2000) — High-Dose PPI After Endoscopic Therapy

• Patients: 240 patients with bleeding peptic ulcers
• Intervention: High-dose omeprazole vs. placebo after endoscopic therapy
• Key Finding: Reduced rebleeding (6.7% vs. 22.5%)
• Clinical Impact: Established PPI after endoscopy
• PMID: 11058884

Sung et al. (2003) — Combination Endoscopic Therapy

• Patients: 156 patients with bleeding ulcers
• Intervention: Injection + thermal vs. injection alone
• Key Finding: Reduced rebleeding (8% vs. 20%)
• Clinical Impact: Established combination therapy as standard
• PMID: 12851875

Evidence Strength

What is Acute Upper GI Bleeding?

Imagine your digestive system as a series of tubes. In acute upper GI bleeding, one of these tubes (your esophagus, stomach, or first part of your small intestine) starts bleeding. You might vomit blood (bright red if fresh, or like coffee grounds if it's been in your stomach) or pass black, tarry stools that look like tar and smell very bad. This happens when something damages the lining of your digestive tract—like an ulcer (a sore), swollen veins (varices), or a tear.

In simple terms: You're bleeding from your stomach or upper intestine, and blood is coming out either when you vomit or in your stools.

Why does it matter?

Acute upper GI bleeding can be serious because you can lose a lot of blood quickly. Your body needs blood to carry oxygen to your organs—without enough blood, your organs can start to fail. Even with the best treatment, about 5-10 out of 100 people don't survive, and this rises to 30-40 out of 100 in people who are already unwell. The good news? Most bleeds stop on their own, and with quick treatment (fluids, blood transfusion if needed, and a camera test to find and treat the cause), most people recover completely.

Think of it like this: It's like a pipe springing a leak—you need to find the leak and fix it before too much water (blood) is lost.

How is it treated?

1. Stopping the Bleeding: Doctors give you fluids and sometimes blood through a drip to replace what you've lost and keep your blood pressure up.

2. Finding the Cause: Doctors do a test called an endoscopy—a thin, flexible camera is passed through your mouth into your stomach to see where the bleeding is coming from. This is done under sedation so you don't feel it.

3. Treating the Bleeding: If the bleeding is still active or looks likely to bleed again, doctors can treat it through the camera:

• Injections: Medicine injected around the bleeding area
• Heat treatment: Cautery to seal the bleeding vessel
• Clips: Small clips to close the bleeding vessel

4. Treating the Underlying Cause:

• If it's an ulcer: Medicines to reduce acid, antibiotics if infection present
• If it's varices: Banding (tying off the swollen veins)
• If it's from medicines: Stop the offending medicine

The goal: Stop the bleeding, find and fix the cause, and prevent it happening again.

What to expect

In the Hospital:

• First few hours: Doctors will act quickly to stabilize you—fluids, blood if needed, and prepare for the camera test
• Day 1: You'll have the endoscopy (camera test) to find and treat the bleeding
• Days 2-3: You'll be monitored closely to make sure the bleeding doesn't start again
• Days 3-5: If everything is stable, you can usually go home

After Going Home:

• Medications: You'll need medicines (usually a PPI like omeprazole) to reduce stomach acid and help healing
• Diet: Usually a normal diet, but avoid alcohol and things that irritate your stomach
• Follow-up: Doctor visits and sometimes repeat camera tests to make sure everything is healed
• Lifestyle: Stop smoking, avoid NSAIDs (like ibuprofen), reduce alcohol if that was a factor

Recovery Time:

• In hospital: Usually 3-5 days
• At home: Most people feel back to normal within 1-2 weeks
• Full healing: Ulcers usually heal within 4-8 weeks with treatment

When to seek help

Call 999 (or your emergency number) immediately if:

• You vomit blood (bright red or coffee-ground)
• You pass black, tarry stools
• You feel very weak or faint
• You feel dizzy or lightheaded
• Your heart is racing
• You feel confused or "not yourself"

See your doctor urgently if:

• You've had upper GI bleeding before and feel unwell again
• You're taking blood thinners and notice dark stools
• You have ongoing stomach pain with other symptoms
• You're losing weight unexpectedly

Remember: If you vomit blood or pass black, tarry stools, don't wait—get emergency help immediately. This can be serious and needs prompt treatment.

Conditions to Consider

Upper GI bleeding must be distinguished from other causes of blood in vomit or stool:

Clinical Differentiation

Upper vs. Lower GI Bleeding:

Hematemesis vs. Hemoptysis:

Mimics & Pitfalls

1. Red Foods/Medications:

• Beetroot: Can cause red stools (not blood)
• Food coloring: Red jellies, drinks
• Medications: Iron (black stools), bismuth (black stools)
• Test: Stool occult blood test (negative if food)

2. Swallowed Blood:

• Sources: Nosebleed, dental bleeding, hemoptysis swallowed
• Clue: No GI symptoms, clear source of bleeding
• Management: Treat source, no GI investigation needed

3. Aortoenteric Fistula (Don't Miss!):

• Clue: Previous aortic graft surgery + "herald bleed" (small bleed before massive)
• Key: High suspicion if any GI bleed post-aortic surgery
• Investigation: Urgent CT angiogram
• Management: Urgent vascular surgery (mortality 50%+ if missed)

Primary Prevention (Before First Bleed)

Medication Review in High-Risk Patients:

PPI Co-Prescription:

• Indication: If high-risk patient on NSAIDs/antiplatelet
• Drugs: Omeprazole 20mg daily, lansoprazole 30mg daily
• Evidence: Reduces ulcer bleeding by 60-70%
• Who: Age >65, previous ulcer, multiple risk factors

H. pylori Screening & Eradication:

• Who: Before starting long-term NSAIDs, previous ulcer history
• Test: Stool antigen, breath test, endoscopy biopsy
• Eradication: Clarithromycin triple therapy (reduces ulcer risk by 90%)

Secondary Prevention (After First Bleed)

Post-Bleeding Management:

Aspirin Restarting:

• Cardiovascular indication (stent, MI, stroke): Restart after 3-5 days
• Primary prevention only: Consider stopping permanently
• Always: Use PPI co-prescription if restarting

Anticoagulation Restarting:

• Timing: Depends on bleeding risk vs. thrombosis risk
• High thrombosis risk (mechanical valve, AF with high CHADS2): Restart early (3-7 days)
• Low thrombosis risk: Can wait longer (1-2 weeks)
• Discuss: Cardiology/hematology input

Tertiary Prevention (Preventing Recurrence)

Lifestyle Modifications:

Variceal Bleeding Prevention:

• Non-selective beta-blockers (propranolol, carvedilol): Reduce portal pressure
• Variceal banding: Elective banding for large varices
• TIPS: If refractory, repeated bleeding

Regular Follow-Up:

• Endoscopy: Repeat at 6-8 weeks to confirm healing (if ulcer)
• H. pylori: Confirm eradication (breath test, stool antigen)
• Medication review: Ensure PPI compliance, no NSAIDs

Elderly Patients (>75 Years)

Epidemiology:

• Incidence: 2-3x higher than younger patients
• Mortality: 15-20% (vs. 5-10% overall)
• Presentation: Often atypical (confusion, falls)

Management Considerations:

Treatment Adjustments:

• Lower transfusion threshold: Hb <80 (vs. <70) if cardiac disease
• Careful fluid balance: Higher risk of pulmonary oedema
• Consider goals of care: Early discussions if very frail

Prognosis:

• Worse than younger patients (mortality 2-3x higher)
• Higher risk of complications (aspiration, AKI)

Anticoagulated Patients

Warfarin:

DOACs (Rivaroxaban, Apixaban, Dabigatran):

• Timing: Note last dose (reversal needed if <24h)
• Reversal agents:
  • Dabigatran: Idarucizumab (Praxbind)
  • Rivaroxaban/Apixaban: Andexanet alfa (if available)
• Alternative: Prothrombin complex concentrate (PCC) if specific reversal unavailable

Restarting Anticoagulation:

• High thrombosis risk: Restart after 3-7 days
• Low thrombosis risk: Can wait 1-2 weeks
• Always: Discuss with cardiology/hematology

Cirrhotic Patients (Variceal Bleeding)

Special Considerations:

Variceal-Specific Management:

• Terlipressin: Reduces portal pressure, start immediately
• Antibiotics: Ciprofloxacin or ceftriaxone (reduces infection, improves survival)
• Band ligation: First-line endoscopic therapy
• TIPS: If refractory bleeding (within 72h if Child-Pugh B/C)

Prognosis:

• Worse than non-variceal bleeding (mortality 15-25%)
• Depends on Child-Pugh score (A = 10%, B = 20%, C = 40% mortality)

Chronic Kidney Disease Patients

Challenges:

Management Adjustments:

• Transfusion threshold: Hb <80 (higher than standard)
• Fluid resuscitation: Cautious, monitor for overload
• Dialysis: Early if fluid overload despite diuretics
• Medications: Dose adjust for renal function

Pregnancy

Rare but Important:

Medications:

• Safe: PPIs (omeprazole), sucralfate
• Avoid: Misoprostol (uterotonic), NSAIDs (late pregnancy)
• Endoscopy: Safe if needed, second trimester ideal

Multidisciplinary Care:

• Obstetrics involvement
• Fetal monitoring if >24 weeks viability
• Consider delivery if maternal instability threatens fetus

Post-Cardiac Surgery / Stent Patients

Dual Antiplatelet Therapy (DAPT):

• Recent stent (<6 months drug-eluting, <1 month bare-metal): Very high thrombosis risk
• Management:
  • Stop aspirin/P2Y12 inhibitor temporarily (if massive bleeding)
  • Restart as soon as possible (ideally <5 days)
  • Discuss with cardiology urgently

Bridge Therapy:

• Not recommended: Heparin bridging increases bleeding risk
• Better: Restart oral antiplatelet as soon as endoscopy done

Last Reviewed: 2025-12-24 | MedVellum Editorial Team

Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists. This information is not a substitute for professional medical advice, diagnosis, or treatment.