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Upper Gastrointestinal Bleeding

NICE Clinical guideline [CG141] Acute upper gastrointestinal bleeding in over 16s: management. Last updated: Aug 2016. NICE guideline [NG24] Blood transfusion. Published: Nov 2015. MHRA Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents. Published: Jun 2020. BSG Best Practice Guidance: outpatient management of cirrhosis – part 2: decompensated cirrhosis.

Background Information

Upper GI bleed: bleeding that originates from a source proximal to the ligament of Treitz (duodenal-jejunal ligament).

Guidelines

NICE recommends the following scores to stratify patients:
 

Note that the Rockall score includes endoscopic findings, thus can only be performed AFTER endoscopy.

A standard work-up for acute GI bleed would include:

  • CBC, U&E
  • Coagulation tests - PT/INR, APTT
  • Blood type and crossmatch

Consider early discharge in those with a pre-endoscopy Blatchford score of 0.
 

Various transfusion thresholds:
 
Component Cut-off
Whole blood Haemoglobin <70 g/L
Platelet Platelet count <50 x 109 /L + actively bleeding
Fresh frozen plasma PTProthrombin time (or INR) or APTTActivated partial thromboplastin time >1.5x normal
Cryoprecipitate Fibrinogen level <1.5 g/L despite fresh frozen plasma
Recombinant factor VIIa Only considered if all other methods have failed

Anticoagulation reversal agent:
 
Anticoagulant Reversal agent
Warfarin Prothrombin complex concentrate (only consider fresh frozen plasma as 2nd line)
Dabigatran Idarucizumab
Apixaban and rivaroxaban Andexanet alfa

Note that there is no reversal agent for edoxaban

Definitive management is endoscopic haemostasis
  • Unstable patients → resuscitate, then immediate endoscopy
  • Stable patients → endoscopy within 24 hours after admission

Endoscopic management depends on the source of bleeding.
 

Offer one of the following for endoscopic haemostasis:
  • Mechanical method (e.g. clip) +/- adrenaline
  • Thermal coagulation with adrenaline
  • Fibrin / thrombin with adreanline

Post-endoscopy PPI is recommended if there are signs of recent or active bleeding at endoscopy (reduces risk of rebleeding and need for surgery)
  • NICE specifically recommends against routine pre-endoscopic PPI (as it makes endoscopic bleeding less visible and does not improve key clinical outcomes like rebleeding, need for surgery and mortality)
 

If patient is stable → consider repeat endoscopy

If patient is unstable:
  • 1st line: interventional radiology
  • If not available promptly → urgent surgery

Pre-endoscopic management (in addition to resuscitation) for ALL suspected variceal bleeding:
  • Terlipressin (stop after 5 days or after definitive haemostasis), and
  • Prophylactic antibiotic

Endoscopic interventions:
  • Oesophageal varices → band ligation
  • Gastric varices → cyanoacrylate glue injection (chemical ligation)
 
  • If failed → TIPSTransjugular intrahepatic portosystemic shunts

 

NICE does not recommend the routine use of the Sengstaken-Blakemore tube (a type of balloon tamponade), due to risk of complications like aspiration and oesophageal perforation.

However, it is still occasionally used in emergencies when endoscopic treatment fails or endoscopy is not immediately available in massive bleeding.

Offer all the following:
  • Carvedilol
  • Variceal band ligation every 4 weeks until eradication
  • Surveillance upper GI endoscopy

References

Author: Adams Lau
Reviewer:
Last edited: 06/08/25