Decision support only — activate senior, endoscopy and critical-bleeding pathways early. Treat suspected variceal bleeding before endoscopy. Verify local transfusion, reversal and antimicrobial protocols.
1 First hours: physiology sets the pace
Unstable / exsanguinatingshock, ongoing haematemesis, poor perfusion
ABCDE; two large-bore IV/rapid access; FBC, UEC, LFT, INR/APTT, fibrinogen, VBG/lactate, group & crossmatch. Look for cirrhosis and anticoagulants.
Activate local major-haemorrhage protocol; balanced components and calcium guided by bleeding, labs/viscoelastic testing. Airway only if unable to protect it or peri-procedure risk. NBA
Stabilised, high riskGBS >1, comorbidity, suspected portal bleed
Resuscitation response, haemoglobin trend, urea/creatinine, syncope, melaena, cardiac/liver disease. Calculate Glasgow–Blatchford score.
Admit and scope after resuscitation: non-variceal within 24 h; suspected variceal within 12 h. Earlier endoscopy is not a substitute for haemodynamic control. ESGE 2026
Very low riskGBS 0–1 and reliable follow-up
Normal observations, no ongoing bleeding or major competing reason for admission; outpatient endoscopy can be arranged.
Consider discharge with safety-net and expedited outpatient pathway. GBS alone does not overrule clinical concern. ACG/ESGE
Restrictive transfusion is the default, not an absolute: haemoglobin <70 g/L generally; individualise upward for active exsanguination, ischaemia or significant cardiovascular disease.
2 Before endoscopy
Likely non-variceal
- PPIConsider high-dose IV PPI while awaiting endoscopy; do not delay the scope. Post-scope regimen depends on stigmata. ESGE 2026
- Prokineticerythromycin 250 mg IV 30–90 min pre-scope for severe/active bleeding if no QT contraindication; metoclopramide is an alternative if erythromycin is unavailable. ESGE 2026
- NGTDo not use lavage routinely. It rarely changes the need for endoscopy.
Suspected variceal
- VasoactiveStart immediately: terlipressin, octreotide or somatostatin per local protocol; continue 2–5 days or until TIPS strategy is settled. GESA/Baveno VIII
- AntibioticGive at presentation; third-generation cephalosporin is usual where quinolone resistance is relevant. Tailor to allergy and local ecology.
- EncephalopathyTreat precipitating bleed and use oral/enema lactulose when indicated. Avoid sedative accumulation.
Do not make the bleed worse
- TXADo not give routinely. HALT-IT found no mortality benefit and more venous thromboembolism/seizures.
- PlateletsDo not transfuse to a reflex number outside the major-haemorrhage pathway; integrate bleeding, count, function and planned procedure.
- FFPINR in cirrhosis does not measure haemostatic balance. Avoid automatic plasma solely to “correct” it.
3 Antithrombotics and reversal
| Drug / indication | During major bleeding | Restart |
|---|
| Aspirin — secondary prevention | Prefer not to stop. If interruption is unavoidable, secure haemostasis and involve cardiology for recent ACS/stent. | Resume as soon as possible, preferably within 3–5 days. ESGE |
| Dual antiplatelet therapy | Continue aspirin if feasible; discuss any P2Y12 interruption urgently with cardiology/interventional team. | Reinstate P2Y12, usually within 5 days if still indicated; timing is lesion- and stent-specific. |
| Warfarin | Major/life-threatening bleed: hold; use PCC plus IV vitamin K per local reversal protocol. Do not delay urgent endoscopy for a modest INR once resuscitation is underway. | As soon as haemostasis and thrombotic risk allow; bridge only for selected very-high-risk indications. |
| DOAC | Hold; record drug, dose, last ingestion and renal function. Specific reversal/PCC is reserved for severe ongoing bleeding after specialist discussion. | Individual plan based on haemostasis, renal clearance and indication. Mechanical prophylaxis while bleeding is active. |
4 Endoscopic treatment
| Finding | What to do | Afterwards |
|---|
| FIa spurting / FIb oozing ulcer | Epinephrine injection only as a bridge; add thermal or mechanical therapy. Haemostatic powder/gel is rescue, not preferred sole first-line therapy. ESGE 2026 | High-dose PPI for 72 h, then oral PPI twice daily to day 14. |
| FIIa visible vessel | Treat with contact thermal, clips or over-the-scope clip as appropriate to site and expertise. | Same high-dose PPI pathway. |
| FIIb adherent clot | Irrigate; management after a persistent clot is operator- and lesion-dependent. Do not force clot removal without a haemostasis plan. | High-dose PPI if treated/high risk. |
| FIIc flat spot / FIII clean base | No endoscopic haemostasis. | Standard oral PPI; early feeding and discharge if otherwise suitable. |
| Oesophageal varix | Endoscopic variceal ligation. Gastric/fundal varix needs an experienced endoscopist and early IR/TIPS/obliteration planning. | Continue vasoactive/antibiotic plan; secondary prophylaxis with NSBB plus serial ligation unless TIPS pathway. |
5 Failure, rebleeding and TIPS
Non-variceal failure
- PersistentUse over-the-scope clip or topical haemostatic agent for refractory standard therapy. If endoscopic options fail: transcatheter arterial embolisation; surgery if embolisation is unavailable or unsuccessful. ESGE 2026
- RebleedRepeat endoscopy, favouring over-the-scope clip for suitable lesions; then embolisation.
- High riskDiscuss prophylactic embolisation after haemostasis for selected unstable patients, posterior duodenal ulcer, ulcer >2 cm or uncertain durability.
Variceal failure / pre-emptive TIPS
- BridgeUncontrolled oesophageal bleeding: covered self-expanding metal stent is preferred over balloon tamponade where available; either is a bridge, not definitive care.
- pTIPSDiscuss urgently for Child–Pugh C 10–13, Child B >7 with active bleeding at endoscopy, or HVPG ≥20 mmHg; perform within 72 h, ideally 24 h. Baveno VIII
- ImagingContrast CT/MRI after stabilisation to define portal-vein thrombosis, HCC and collaterals when variceal bleeding is confirmed/suspected.
6 Cause, recovery and discharge
Close the loop
- H. pyloriTest in peptic-ulcer bleeding; treat if positive and confirm eradication. A negative acute test can be false: repeat off PPI when appropriate.
- NSAIDsStop if possible. If unavoidable, use the lowest exposure with PPI and reassess the indication.
- CancerBiopsy suspicious gastric lesions; document pathology and repeat endoscopy plan.
After durable haemostasis
- NutritionRestart oral intake within 24 h unless procedure/aspiration risk says otherwise. ESGE 2026
- IronCheck iron studies after resuscitation; start replacement before discharge when iron deficient/anaemic.
- HandoverRecord lesion, Forrest class, therapy, transfusion, antithrombotic restart date, PPI duration, H. pylori plan and return precautions.
Guidelines & reviews. ESGE Guideline: diagnosis and management of non-variceal upper gastrointestinal haemorrhage, Endoscopy 2026; ACG Upper Gastrointestinal and Ulcer Bleeding guideline 2021; GESA portal-hypertension consensus 2026; Baveno VIII consensus 2026; National Blood Authority Patient Blood Management guideline for adults with critical bleeding 2023, updated 2025. Trials. Villanueva et al., restrictive vs liberal transfusion, NEJM 2013; HALT-IT, tranexamic acid, Lancet 2020; Sung et al., continuation of low-dose aspirin after ulcer bleeding, Ann Intern Med 2010; García-Pagán et al., early TIPS, NEJM 2010. Caveats. Drug reversal, antimicrobial choice, transfusion ratios and endoscopy timing must follow local resources and senior judgement. Companion cirrhosis sheets cover ascites, encephalopathy and longer-term portal care.