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Upper GI bleed
Resuscitate first, risk-score second, scope at the right time. Treat shock, call the major haemorrhage protocol if needed, decide whether it could be variceal (because that changes the drugs), score the risk, and arrange endoscopy at the right time. Built for revision, not live patient decisions.
Settle them, and check the basics
resuscitateRed flags — what each should make you think
The Hb can be normal in the first hours of a big bleed, because it takes time to haemodilute. Judge the patient by their pulse, BP, CRT and ongoing loss. A young patient can bleed a lot before the BP drops.
Resuscitation
- IVTwo large-bore cannulas
- 🩸Major haemorrhage protocol
- HbRestrictive transfusion
- TeSuspected varices?
- ↩Reverse anticoagulation
- ☎Endoscopy team
Understand the patient
score · variceal?Risk scores (NICE)
- Glasgow-Blatchford score at first assessment (urea, Hb, SBP, pulse, melaena, syncope, liver disease, heart failure). A score of 0 can be considered for early discharge with outpatient endoscopy
- Full Rockall score after endoscopy (age, shock, comorbidity, diagnosis, stigmata of bleeding)
- Endoscopy — immediately after resuscitation if unstable; within 24 h for everyone else admitted
Variceal vs non-variceal
- Variceal — terlipressin, prophylactic antibiotics, band ligation at endoscopy; balloon tamponade or TIPSS for uncontrolled bleeding
- Non-variceal (ulcer) — endoscopic therapy; PPI after endoscopy (not routinely before, per NICE); test for H. pylori; stop NSAIDs
- Other causes: Mallory–Weiss tear, oesophagitis, gastritis, malignancy, Dieulafoy lesion
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Known cirrhosis, alcohol, jaundice, ascites, spider naevi; large-volume haematemesis.
Endoscopy.
Resuscitate (avoid over-transfusion), terlipressin, IV antibiotics, urgent endoscopy for banding; balloon tamponade/TIPSS if uncontrolled; ITU.
Haematemesis/melaena with shock, NSAIDs, anticoagulants, previous ulcer.
Endoscopy.
Resuscitate, MHP, endoscopic haemostasis; if fails → interventional radiology embolisation or surgery.
Sudden severe epigastric pain, rigid abdomen, may have haematemesis.
Erect CXR (free air), CT.
Surgical emergency. See the perforation page.
GI bleed (often a "herald" small bleed first) in someone with an aortic graft or AAA.
CT angiogram.
Vascular surgery emergency.
Investigate — what to order, when, and what it tells you
test with a question in mindBloods
Scores
Endoscopy
Other
How the plan comes together
disposition · handoverhome
Glasgow-Blatchford 0, stable, no ongoing bleeding — consider discharge with outpatient endoscopy.
admit / HDU
Everyone else; HDU/ITU for haemodynamic instability, variceal bleeding, or airway risk.
Hand over: GBS, blood given, variceal or not, endoscopy timing, reversal given.
Resuscitate, think "could this be varices?", score it, and get the right scope at the right time. And don't trust the first Hb. Nicely done getting here.
Clerking template
copy or downloadUpper GI bleed — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 10 knownFrequently asked questions
quick answersWhat are the red flags for an upper GI bleed?
- Shock, ongoing haematemesis — think major haemorrhage
- Liver disease, alcohol, ascites — think variceal bleed
- Melaena + haemodynamic instability — think high-risk bleed
- On anticoagulants / antiplatelets — think reversal decisions
- Previous AAA repair + GI bleed — think aorto-enteric fistula
- Peritonism + haematemesis — think perforated ulcer
What is the initial management of an upper GI bleed?
- Two large-bore cannulas — FBC, U&E (urea), LFT, clotting, crossmatch
- Major haemorrhage protocol — if shocked with ongoing bleeding
- Restrictive transfusion — usually transfuse at Hb below 70 g/L, aiming for 70–90 (higher with cardiovascular disease), unless massive bleeding
- Suspected varices? — terlipressin + prophylactic antibiotics before endoscopy
- Reverse anticoagulation — per local policy; platelets if below 50 and actively bleeding
- Endoscopy team — immediately after resuscitation if unstable
Always alongside senior support and your local guideline.
What diagnoses must you not miss in an upper GI bleed?
- Variceal haemorrhage — liver disease · massive
- Major non-variceal bleed — ulcer · shock
- Perforated ulcer — peritonism
- Aorto-enteric fistula — previous aortic graft
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for an upper GI bleed?
- Bloods — FBC, U&E (raised urea out of proportion to creatinine suggests upper GI blood), LFT, clotting, group and crossmatch.
- Scores — Before endoscopy.
- Endoscopy — Immediately after resuscitation if unstable; within 24 h for others.
- Other — Ongoing bleeding when endoscopy fails or source unclear.
Admit or discharge: how is the plan decided for an upper GI bleed?
- Home — Glasgow-Blatchford 0, stable, no ongoing bleeding — consider discharge with outpatient endoscopy.
- Admit / hdu — Everyone else; HDU/ITU for haemodynamic instability, variceal bleeding, or airway risk.
Is there a clerking template for an upper GI bleed?
Yes — there is a clerking template for an upper GI bleed on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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