Based on recommendations from National Institute for Health and Care Excellence (NICE), translated into what you actually do on call, not policy language.

This is designed for:
👉 IMGs
👉 F1–IMT doctors
👉 medical on-call shifts

Why this matters

Upper GI bleeding is one of the most dangerous and time-critical gastro emergencies you’ll see in the NHS.

Patients can:

look stable
then crash quickly

Good early management saves lives.

Your job is NOT to memorise scores.

Your job is to:

resuscitate early, risk-stratify, and scope at the right time

✅ Step 1 – Recognise it fast

Typical presentations

Haematemesis
Coffee-ground vomit
Melaena
Unexplained anaemia
Syncope
Shock

Remember:
👉 melaena alone = GI bleed until proven otherwise

🚨 Step 2 – Immediate management (first 10 minutes)

This is what NICE expects you to do straight away.

Do immediately

A–E assessment

Always first

IV access

2 large bore cannulas

Bloods

FBC
U&E
LFTs
Clotting
Group & save
Crossmatch if significant bleed

Resuscitate

IV fluids
Oxygen if needed

NBM

Monitor

Obs
Urine output
Hb trends

Do NOT wait for gastro review to start these.

✅ Step 3 – Risk stratify (who is sick?)

You don’t need complicated scoring.

Think clinically.

High-risk features (escalate early)

Hypotension
Tachycardia
Ongoing haematemesis
Hb falling
Known cirrhosis
Syncope/confusion
NEWS ≥5

👉 These patients need urgent senior input ± HDU/ICU

Never “watch and wait”.

✅ Step 4 – Start early treatment

For ALL suspected UGIB

👉 Start IV PPI
(e.g. omeprazole infusion or bolus)

If cirrhosis or varices suspected

Start immediately:

Terlipressin
IV antibiotics (e.g. ceftriaxone)

Don’t wait for scope confirmation.

This is specifically recommended because:
👉 reduces mortality

Very commonly forgotten by juniors.

✅ Step 5 – Timing of endoscopy (very exam + ward relevant)

Stable patients

👉 Endoscopy within 24 hours

Unstable/high-risk patients

👉 Urgent endoscopy after resuscitation
(same day)

Suspected variceal bleed

👉 As soon as possible

Remember:
Endoscopy is both:

diagnostic
therapeutic

(clips, banding, injection)

✅ Step 6 – Transfusion strategy (important concept)

Over-transfusion worsens outcomes.

Target Hb:

👉 70–90 g/L (most patients)

Transfuse only if:

symptomatic
unstable
very low Hb

Don’t chase “normal Hb”.

✅ Step 7 – After endoscopy

Depends on findings:

Non-variceal (e.g. ulcer)

PPI
monitor

Varices

banding
continue terlipressin
antibiotics
hepatology follow-up

Low-risk findings

early discharge possible

✅ Who can go home early?

Low-risk patients:

stable obs
no ongoing bleed
reassuring scope

Can sometimes be discharged with outpatient follow-up.

Not everyone needs admission for days.

🚨 When you MUST escalate urgently

Call senior/gastro/ICU if:

haemodynamic instability
ongoing haematemesis
massive melaena
Hb rapidly dropping
suspected varices
elderly/frail with shock

Early escalation saves lives.

No one criticises early help.

❌ Common junior mistakes (very high yield)

Delaying IV access
Forgetting terlipressin/antibiotics in cirrhosis
Waiting for gastro before resuscitating
Over-transfusing
Underestimating melaena
Not documenting haemodynamics
Late escalation

Most harm happens before endoscopy.

✅ Simple on-call algorithm (easy to remember)

When called for UGIB:

A–E
2 cannulas + bloods
Fluids
PPI
Terlipressin + antibiotics if liver disease
Escalate if unstable
Scope within 24h (earlier if high risk)

That’s 95% of management.

✅ Take-home concept

UGIB management is about resuscitation and early escalation, not memorising causes.
Stabilise first, scope second.

If you do that well, you’re already practicing safely.