Upper GI Haemorrhage

1. Recognise the syndrome and the airway risk

Upper GI bleeding may present with fresh haematemesis, coffee-ground vomiting, melaena or, in rapid major bleeding, haematochezia. The apparent volume of vomited blood does not reliably measure total blood loss. Tachycardia, hypotension, poor peripheral perfusion, altered mental state and reduced urine output matter more than visual estimation.

Airway protection is selective. Uncontrolled haematemesis, severe encephalopathy, agitation or inability to protect the airway should prompt early anaesthetic involvement. Routine prophylactic intubation is not required for every patient.

2. Risk-stratify before endoscopy

The Glasgow-Blatchford score uses urea, haemoglobin, systolic blood pressure, pulse, melaena, syncope, hepatic disease and cardiac failure. NICE CG141 recommends using it at first assessment and considering early discharge when the score is 0. Contemporary ESGE guidance identifies 0–1 as a very-low-risk range that may be suitable for outpatient management when clinical and social circumstances are appropriate.

The full Rockall score is calculated after endoscopy and incorporates age, shock, comorbidity, diagnosis and endoscopic stigmata. Use scores to support—not replace—clinical judgement. Haemodynamic instability and active bleeding override numerical thresholds.

3. Initial resuscitation

• ABCDE, immediate senior review, monitoring and large-bore IV access.
• Send FBC, renal and liver tests, coagulation, fibrinogen, lactate and crossmatch according to severity/local protocol.
• Use judicious crystalloid while blood is prepared; activate the local major-haemorrhage protocol for ongoing severe bleeding.
• During active shock, transfuse according to physiology rather than waiting for a later haemoglobin threshold.
• For stable adults without major haemorrhage or acute coronary syndrome, NICE NG24 supports a restrictive red-cell threshold around 70 g/L with a post-transfusion target of 70–90 g/L; in acute coronary syndrome it advises considering 80 g/L with a target of 80–100 g/L.
• Review anticoagulants and antiplatelets urgently; reversal and continuation decisions depend on the drug, indication, bleeding severity and specialist/local protocols.

4. Timing of endoscopy

The 2026 ESGE peptic-ulcer guideline emphasises that routine emergent (≤6 h) or urgent (≤12 h) endoscopy is not beneficial for non-variceal peptic-ulcer bleeding unless haemodynamic instability persists despite adequate resuscitation. This is compatible with prioritising resuscitation before endoscopy.

5. Peptic-ulcer and other non-variceal bleeding

• Endoscopically treat actively bleeding ulcers and non-bleeding visible vessels using an effective mechanical, thermal or guideline-supported combination technique.
• Adrenaline/epinephrine injection must not be used as monotherapy.
• Under NICE CG141, do not routinely give acid suppression before endoscopy for suspected non-variceal UGIB. ESGE 2026 allows high-dose IV PPI to be considered before endoscopy, but it must not delay endoscopy; follow the local UK protocol.
• After successful endoscopic haemostasis of high-risk peptic-ulcer stigmata, use high-dose PPI therapy according to the local evidence-based regimen.
• If clinically significant rebleeding occurs, repeat endoscopic treatment is the usual next step; if endoscopic control fails, transcatheter angiographic embolisation is preferred where available, with surgery when embolisation is unavailable or unsuccessful.

6. Suspected variceal bleeding

• Start a guideline-supported vasoactive agent at presentation (for example terlipressin according to UK/local protocol) rather than waiting for endoscopic confirmation.
• Give prophylactic antibiotics from presentation; regimen should follow local resistance, allergy and liver-disease policy.
• Perform endoscopy within 12 hours once haemodynamically resuscitated.
• Use band ligation for oesophageal varices; gastric-variceal management differs and may require tissue adhesive or specialist endovascular approaches.
• High-risk patients may be considered for pre-emptive TIPS within 72 hours, preferably within 24 hours, according to specialist criteria.
• Persistent uncontrolled oesophageal-variceal bleeding requires rescue therapy and urgent TIPS planning; a covered oesophageal stent may be used as a bridge where available, while balloon tamponade is a temporary alternative in expert care.

7. Mallory–Weiss versus Boerhaave syndrome

8. MRCS answer structure

A safe viva answer is chronological: “I would assess airway and circulation, obtain large-bore IV access and bloods/crossmatch, resuscitate according to physiology, calculate the Glasgow-Blatchford score once immediate threats are addressed, review antithrombotic therapy, and arrange appropriately timed endoscopy. If variceal bleeding is suspected I would start vasoactive therapy and prophylactic antibiotics immediately. Definitive escalation depends on the endoscopic source and whether haemostasis is achieved.”