Upper GI Bleed 🩸
BSG-led acute upper GI bleeding care bundle with Glasgow-Blatchford calculator. Recognition, resuscitation, risk stratification, treatment, referral, and review for on-call doctors.
Glasgow-Blatchford Score
Pre-endoscopy risk stratification for upper GI bleeding
Sex (for Hb bands)
Blood urea
Haemoglobin
Systolic BP
Other features
📋 How to use this topic
- Calculate the Glasgow-Blatchford Score (GBS) at presentation using the calculator — BSG recommends GBS for all AUGIB.
- GBS ≤1: consider for outpatient management after senior review (if clinically appropriate).
- Trigger the AUGIB bundle for haematemesis, melaena, or coffee-ground vomiting (CGV) unless an alternate diagnosis is clear.
- This is an educational aid — follow local major haemorrhage and AUGIB protocols.
🔍 Recognition — trigger the bundle
- Haematemesis, melaena, or coffee-ground vomiting (CGV) in the absence of an alternate diagnosis (e.g. bowel obstruction).
- Perform urgent observations using a validated early warning score (e.g. NEWS).
- Assess haemodynamic status and reassess regularly.
💧 Resuscitation
- All patients: commence IV crystalloid; monitor NEWS and review clinically to guide infusion rate.
- Haemodynamically unstable: 500 mL crystalloid bolus over <15 minutes.
- Restrictive RBC transfusion: trigger Hb <70 g/L, target 70–100 g/L. Consider a higher trigger in ischaemic heart disease or haemodynamic instability.
- Ongoing haemodynamic instability despite resuscitation: consider activating major haemorrhage protocol and arrange critical care review.
- Suggested (weak evidence): platelets if active bleeding with platelet count ≤50×10⁹/L, per major haemorrhage protocol.
📊 Risk stratification (GBS)
- BSG bundle: calculate Glasgow-Blatchford Score at presentation for all AUGIB.
- GBS ≤1: consider for outpatient management (BSG strong recommendation).
- GBS is the best pre-endoscopy score for predicting need for hospital-based intervention (transfusion, endoscopic therapy, interventional radiology, surgery) or death, with high sensitivity (~99%).
- Scores above 1 generally warrant admission and standard in-hospital AUGIB care, including endoscopy within 24 hours.
💊 Treatment (Rx)
- Suspected cirrhosis/variceal bleeding: IV terlipressin 2 mg four times daily (caution in ischaemic heart disease or peripheral vascular disease). IV antibiotics per local protocol.
- Continue aspirin at presentation.
- Interrupt P2Y12 inhibitors until haemostasis; if coronary artery stents, discuss with cardiology — ideally continue DAPT where possible. If P2Y12 is stopped, continue aspirin and aim to restart P2Y12 within 5 days.
- Interrupt warfarin and DOACs at presentation.
- When antithrombotic therapy is interrupted, document a clear plan for resumption.
- Post-endoscopy: high-dose IV PPI for ulcers with high-risk stigmata (high-dose oral PPI may be an alternative).
📞 Referral & endoscopy
- Offer endoscopy within 24 hours of presentation to patients admitted with suspected AUGIB.
- Ongoing haemodynamic instability: more urgent endoscopy after resuscitation.
- Refer to a specialist gastroenterology service if varices are identified or therapeutic endoscopy is performed.
- Suggested: ward team should review the endoscopy report on return to the ward (findings, haemostasis, rebleeding plan).
🚩 Escalate urgently
- Haemodynamic instability despite resuscitation — major haemorrhage protocol, critical care review.
- Large-volume or ongoing bleed.
- Exsanguinating haemorrhage — manage per major haemorrhage guidelines (Hb may not reflect blood loss).
Disclaimer
- Educational aid only. Acute upper GI bleeding requires senior input and local protocol. Confirm all management with hospital policy and gastroenterology/surgical teams.
Related NICE guidance
NICENICE CG141 — Acute upper gastrointestinal bleeding in over 16s: management
Full guidance on nice.org.uk. BetterCall is not endorsed by NICE.
Educational reference only. Medical disclaimer