First moves
Two large-bore IVs, crossmatch, and fluid resuscitation before anything diagnostic.
Transfusion threshold: haemoglobin < 70 g/L for most patients, or < 80 g/L with cardiovascular disease. Liberal transfusion increases mortality in variceal bleeding by raising portal pressure — a favourite exam point.
Correct coagulopathy and consider reversal agents; hold anticoagulants and antiplatelets after weighing the indication.
Is it variceal or not?
The answer changes the pre-endoscopic drugs:
Suspected variceal bleeding (known cirrhosis, stigmata of chronic liver disease):
- Octreotide or terlipressin infusion
- Prophylactic antibiotics — ceftriaxone. This reduces mortality, not just infection, and is the most commonly forgotten step
- Endoscopy within 12 hours for band ligation
- Consider TIPS early in high-risk patients
Non-variceal (peptic ulcer, the commonest):
- High-dose proton pump inhibitor, infusion or intermittent high dose
- Endoscopy within 24 hours
Risk stratification
The Glasgow–Blatchford score identifies patients at low enough risk for outpatient management — a score of 0–1 means no intervention is likely to be needed. Rockall predicts mortality and uses endoscopic findings.
Endoscopic therapy and after
Combination therapy for high-risk stigmata (active bleeding, visible vessel, adherent clot): injection plus a second modality — clips or thermal coagulation. Injection alone is inadequate.
After a bleeding ulcer:
- Test for H. pylori and treat if positive, then confirm eradication. Testing during acute bleeding gives false negatives, so retest later if negative
- Stop NSAIDs where possible; if they must continue, cover with a PPI
- Rebleeding is managed with repeat endoscopy first; then interventional radiology (embolisation) or surgery
Where else the blood might be coming from
- Mallory–Weiss tear — vomiting then haematemesis; usually self-limiting
- Aorto-enteric fistula — previous aortic graft, a herald bleed then exsanguination
- Angiodysplasia — associated with aortic stenosis and renal failure
- Dieulafoy lesion — a large submucosal artery, hard to find, dramatic bleeding
- Malignancy
A brisk upper GI bleed can present as fresh rectal bleeding. If a patient with haematochezia is haemodynamically unstable, look upwards first.