Gastrointestinal & Hepatic · Topic 1 of 26

Upper GI Bleeding

Gastrointestinal · GI bleeding

Upper GI Bleeding

Resuscitate, transfuse only below hemoglobin 7, scope within 24 hours, and give high-dose PPI after the ulcer is treated.

Key numbers

Transfuse RBCs below hemoglobin 7 g/dLHgb < 7 (8 with CVD)

High-dose PPI for 3 days after hemostasis80 mg + 8 mg/h × 3 d

Upper endoscopy within 24 hoursEGD ≤ 24 h

Glasgow-Blatchford 0–1: discharge with follow-upGBS 0–1

01 · DoTransfuse RBCs below hemoglobin 7 g/dL

Use a restrictive strategy: transfuse red cells when hemoglobin falls below 7 g/dL, or below 8 g/dL with pre-existing cardiovascular disease; hypotensive, massively bleeding patients may need blood at higher levels.

02 · FirstUpper endoscopy within 24 hours

Perform upper endoscopy within 24 hours of presentation in admitted patients, after resuscitation; endoscopy within 6 hours did not lower mortality even in high-risk patients (Glasgow-Blatchford 12 or more).

03 · GiveHigh-dose PPI for 3 days after hemostasis

After endoscopic hemostasis of a high-risk ulcer, give high-dose PPI for 3 days (80 mg IV bolus then 8 mg/h, or 40 mg 2–4 times daily), then oral PPI twice daily through week 2.

Causes & risk factors

Why it happens

Peptic ulcer is the leading causeGastric and duodenal ulcers cause up to half of upper GI bleeding; others are varices, Mallory-Weiss tears after retching, erosive esophagitis and gastroduodenal erosions. Test bleeding-ulcer patients for H. pylori.

Presentation

What you'll see

Melena usually means an upper sourceMelena usually indicates upper GI bleeding (about 100–200 mL of blood) and coffee-ground emesis a slowed bleed; brisk upper bleeding can present as hematochezia with shock.

Diagnosis & monitoring

Work-up

Glasgow-Blatchford 0–1: discharge with follow-up must knowRisk-stratify in the emergency department: a Glasgow-Blatchford score of 0–1 identifies very-low-risk patients who can be discharged with outpatient follow-up instead of admission.

Treat active bleeding and visible vessels endoscopicallyEndoscopic hemostasis is indicated for ulcers with active spurting or oozing and for nonbleeding visible vessels; a clean-based ulcer needs no endoscopic therapy, and adherent clots may be treated or not.

Do right now

In this order

First moves

Two large-bore IVs, fluids, protect the airway

→

Transfuse RBCs below hemoglobin 7 g/dLHgb < 7 (8 with CVD)

→

Erythromycin 250 mg IV before endoscopy

→

Upper endoscopy within 24 hoursEGD ≤ 24 h

→

High-dose PPI for 3 days after hemostasis80 mg + 8 mg/h × 3 d

Why each step

Two large-bore IVs, fluids, protect the airwayResuscitate first: two short large-bore (14–16 gauge) IVs, crystalloid, monitored or ICU bed, and endotracheal intubation for obtundation or poor gag — aspiration of blood is a major cause of death.

Transfuse RBCs below hemoglobin 7 g/dLUse a restrictive strategy: transfuse red cells when hemoglobin falls below 7 g/dL, or below 8 g/dL with pre-existing cardiovascular disease; hypotensive, massively bleeding patients may need blood at higher levels.

Erythromycin 250 mg IV before endoscopyGive erythromycin 250 mg IV 20–90 minutes before endoscopy to empty the stomach of blood; it reduces repeat endoscopy and hospital days. Avoid with QT prolongation or interacting drugs.

Upper endoscopy within 24 hoursPerform upper endoscopy within 24 hours of presentation in admitted patients, after resuscitation; endoscopy within 6 hours did not lower mortality even in high-risk patients (Glasgow-Blatchford 12 or more).

High-dose PPI for 3 days after hemostasisAfter endoscopic hemostasis of a high-risk ulcer, give high-dose PPI for 3 days (80 mg IV bolus then 8 mg/h, or 40 mg 2–4 times daily), then oral PPI twice daily through week 2.

Management

Orders

IV PPI before endoscopy is optionalACG 2021 makes no recommendation for or against pre-endoscopic IV PPI: it does not reduce rebleeding or mortality but may modestly reduce endoscopic therapy; it may be given, especially when endoscopy will be delayed.

Cirrhosis: add octreotide and ceftriaxone nowIn known or suspected cirrhosis treat upper GI bleeding as variceal until proven otherwise: start octreotide (or another vasoactive drug) and IV ceftriaxone before endoscopy.

Rebleeding: repeat endoscopy, then embolizationRecurrent ulcer bleeding after endoscopic hemostasis gets a second endoscopy; if endoscopic therapy fails, transcatheter arterial embolization is preferred over surgery (similar mortality, fewer complications).

Keep cardiac aspirin; no platelet transfusionDo not stop aspirin taken for secondary cardiovascular prevention (if interrupted, restart once hemostasis is confirmed), and do not transfuse platelets for antiplatelet drug effect.

Warfarin: no FFP; PCC only if life-threateningMost GI bleeds on warfarin need no reversal: avoid FFP and vitamin K, and give 4-factor PCC only for life-threatening bleeding or a markedly supratherapeutic INR. DOACs: no routine PCC or specific reversal agents.

Red flags & don'ts

Avoid harm

No tranexamic acid for GI bleeding avoidDo not give tranexamic acid: in HALT-IT (about 12,000 patients) it did not reduce death from GI bleeding and nearly doubled venous thromboembolism.

The rules

Know these

No routine nasogastric aspiration or lavageDo not place a nasogastric tube routinely: a nonbloody aspirate does not exclude upper bleeding (up to 15% false negative), and ACG (lower GI 2023) and AASLD (variceal 2024) advise against routine placement.

Upper or lower GI bleeding?

Commonly confused

Typical stool	Melena; hematemesis or coffee grounds
Leading cause	Peptic ulcer
First study	Upper endoscopy within 24 hours
Trap	Brisk upper bleeding can cause hematochezia

More detail

Reference

Show 4 reference facts

Orthostatic vital signs are unreliable and risky in severe bleeding, and hemoglobin falls only after equilibration with fluids, so the initial value underestimates blood loss.

Endoscopic options: bipolar electrocoagulation, heater probe, absolute ethanol injection or clips; hemostatic powder (TC-325) for active bleeding as a bridge, and over-the-scope clips for recurrent bleeding.

On dual antiplatelet therapy, continue aspirin and hold the P2Y12 inhibitor (clopidogrel about 7 days after endoscopic treatment), coordinating with cardiology when the indication is recent.

Mortality from upper GI bleeding in the United States is about 2%; the ABC score (age, labs, comorbidity, ASA class) predicts 30-day mortality in upper and lower bleeding.

Pearl

Seven is the number: transfuse below a hemoglobin of 7 g/dL (8 with cardiovascular disease), and more blood is not better.

Sources · Laine L et al. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol 2021;116:899–917 · Merck Manual Professional — Overview of Gastrointestinal Bleeding (updated Nov 2025) · Abraham NS et al. ACG–CAG Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute GI Bleeding and the Periendoscopic Period. Am J Gastroenterol 2022 · HALT-IT Trial Collaborators. High-dose 24-h tranexamic acid in acute gastrointestinal bleeding. Lancet 2020;395:1927–36 · Lau JYW et al. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. N Engl J Med 2020;382:1299–1308 · Kaplan DE et al. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024;79:1180–1211 · Merck Manual Professional — Peptic Ulcer Disease · TCTMD — Andexanet alfa pulled from the US market (Dec 2025) · Sengupta N et al. Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline. Am J Gastroenterol 2023;118:208–231 · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).