Acute presentations and emergencies

Upper GI bleeding

Overview and approach

Upper GI bleeding presents with haematemesis or melaena; brisk upper bleeding can cause haematochezia.

  • Causes: peptic ulcer, varices/portal hypertensive gastropathy, erosive oesophagitis/gastritis, Mallory-Weiss tear, malignancy, Dieulafoy lesion, angiodysplasia.
  • Separate variceal from non-variceal bleeding early: management differs (1)(2).
Assessment and clinical features

ABCDE, haemodynamic trends, perfusion, comorbidities and antithrombotics; assess liver disease/varices and resuscitate while investigating.

  • History: NSAIDs, aspirin, anticoagulants, alcohol, liver disease, prior ulcer, vomiting before haematemesis (Mallory-Weiss), weight loss.
  • Signs: tachycardia, hypotension, postural drop, pallor, stigmata of chronic liver disease, melaena on PR.
Differentials and investigations

FBC, electrolytes, renal function, coagulation and group/crossmatch; urgent senior review and endoscopy planning. Risk tools supplement clinical assessment.

  • Urea disproportionately raised suggests upper source. Lactate and ECG in unstable or elderly patients. Risk scores (for example Glasgow-Blatchford) can identify low-risk patients; use the local tool and threshold.
Management and follow-up

IV access, targeted fluid/blood resuscitation and gastroenterology involvement; suspected variceal bleeding needs its specific vasoactive/antibiotic pathway. Reversal decisions require senior input.

  • Non-variceal (ACG 2021): endoscopy within 24 hours of presentation; restrictive transfusion threshold haemoglobin 7 g/dL (8 g/dL with cardiovascular disease); erythromycin may be used before endoscopy; after successful haemostasis of an ulcer, high-dose PPI for 3 days then twice-daily PPI to 2 weeks (1)(3).
  • Suspected variceal (Baveno VII): immediate vasoactive drug (terlipressin, somatostatin or octreotide) for 2-5 days, antibiotic prophylaxis from admission, endoscopy within 12 hours after resuscitation (2).
  • Anticoagulant reversal and restart: senior and haematology advice.
Red flags and clinical pearls

Shock, ongoing haematemesis or impaired airway protection demands immediate escalation. An initially normal haemoglobin does not exclude major acute blood loss.

  • Early airway protection if large haematemesis or reduced consciousness.
References
  1. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding (2021)
  2. Baveno VII: Renewing consensus in portal hypertension (PMC)
  3. Gastroenterology Advisor: 2021 ACG guideline summary

Last updated from Sen’s notes on 9 October 2026.