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Upper GI bleed

Emergencies

Resuscitate first. Massive bleeding: activate the major haemorrhage protocol.

Use the Glasgow-Blatchford score before endoscopy and the full Rockall score after.

Act now

  1. 1

    Two large-bore cannulae; send bloods including crossmatch.

  2. 2

    Fluid resuscitation; transfuse red cells using NICE NG24 thresholds unless there is massive bleeding.

  3. 3

    Stop anticoagulants, antiplatelets and NSAIDs; nil by mouth pending endoscopy.

  4. 4

    Suspected variceal bleed: terlipressin and prophylactic antibiotics at presentation.

Assess

  • ABCDE; shock signs (HR, BP, capillary refill, lactate, urine output).
  • Haematemesis, coffee-ground vomit or melaena? Known liver disease or varices, alcohol.
  • Drug chart: anticoagulants, antiplatelets, NSAIDs, SSRIs, steroids.

Investigations

  • FBC, U&E (urea rises with upper GI bleeding), LFT, clotting, fibrinogen, crossmatch, venous gas with lactate, ECG.

Manage

  • Endoscopy immediately after resuscitation if unstable with severe bleeding; within 24 hours of admission for everyone else.
  • Do not give PPIs before endoscopy for suspected non-variceal bleeding — start them after endoscopy if there are stigmata of recent bleeding.
  • Platelets if actively bleeding with count under 50 × 10⁹/L; FFP if PT or APTT over 1.5 × normal; cryoprecipitate if fibrinogen under 1.5 g/L despite FFP.
  • Warfarin with active bleeding: prothrombin complex concentrate plus IV vitamin K.
  • Glasgow-Blatchford score of 0: consider early discharge with outpatient follow-up.
  • Tranexamic acid is not part of NICE CG141 and did not reduce mortality in the HALT-IT trial.

Escalate when

  • Ongoing bleeding, shock, or rebleeding: senior, on-call endoscopist, critical care; surgery or interventional radiology if endoscopic treatment fails.

Doses and prescribing

Terlipressin

2 mg IV every 4 hours until bleeding has been controlled for 24 hours, to a maximum of 48 hours. After the first dose, 1 mg every 4 hours if under 50 kg or not tolerated.

Prothrombin complex concentrate

25–50 units/kg IV (product-specific) with vitamin K 5 mg IV for warfarin-related major bleeding.

Antibiotics for suspected variceal bleeding in cirrhosis per local policy.

Check the BNF and your local formulary before prescribing.

Written to current guidance (NICE CG141, NG24) · sources checked 14 Nov 2026. We watch NICE for updates weekly.

Sources (3)

Reviewed by Aboodee Alhasso, MPharm MRCPharm IP on 14 Nov 2026

Calculators for this

For healthcare professionals, as an aid to clinical judgement — not a substitute for it. Follow your local policy and ask a senior when in doubt.