Upper GI Haemorrhage

Upper GI bleeding (above ligament of Treitz) presents as haematemesis and/or melaena. Risk stratify with Glasgow-Blatchford Score (GBS) pre-endoscopy. Resuscitate before endoscopy. Involve GI on-call early.

Glasgow-Blatchford Score / Rockall Score

The pathway

1 · Resuscitate

Two large-bore IV cannulas (16G+)
Fluid resuscitation with crystalloid
Blood transfusion if Hb <70g/L (or <80 in ACS)
Target SBP >100

2 · Risk stratify

GBS ≥1 requires urgent endoscopy
Score 0 = low risk, may manage outpatient
Rockall score post-endoscopy predicts rebleed/mortality

3 · Bloods

FBC, U&E, LFTs, clotting, group & save (or crossmatch 2–4 units)
Repeat after transfusion

4 · Reverse anticoagulation

Warfarin: vitamin K 5mg IV + prothrombin complex (Beriplex)
DOAC: consider reversal agents if haemodynamically unstable

5 · Protect airway

In active haematemesis with reduced GCS: intubation before endoscopy to protect airway.

6 · PPI infusion

Omeprazole 80mg IV bolus then 8mg/hr infusion
For high-risk stigmata post-endoscopy

7 · Endoscopy timing

Unstable with severe bleeding: immediately after resuscitation — NICE CG141 1.3.1
Everyone else: within 24 hours of admission

8 · Post-endoscopy

Restart anticoagulation after discussion (usually 7 days for AF)
H. pylori test and treat
PPI 8 weeks

Drugs

Drug	Dose	Route	Notes
Omeprazole	80mg bolus then 8mg/hr	IV	Post-endoscopy for high-risk stigmata.
Terlipressin	2mg	IV	Q6h if variceal bleed suspected (portal hypertension). Reduces portal pressure.
Vitamin K	5mg	IV	Warfarin reversal. Takes 6–12h to work.
Prothrombin complex (Beriplex)	25–50 units/kg	IV	Immediate warfarin reversal in emergency.

When to escalate

Haemodynamic instability (SBP <90) not responding to resuscitation,Active haematemesis with reduced GCS (airway risk),Suspected variceal bleeding (portal hypertension),Rebleed post-endoscopy,Surgical intervention required (IR or emergency OT)

Reference: BSG Guidelines for the Management of Acute Upper GI Bleeding 2019

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