About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Upper GI bleed = proximal to ligament of Treitz. Presents with haematemesis (fresh red or coffee-ground) and/or melaena
- Use Glasgow-Blatchford score (GBS) at presentation for risk stratification — GBS 0 = very low risk, consider outpatient management
- Urgent OGD within 24 hours for all significant upper GI bleeds (within 2 hours if suspected variceal bleed)
- Non-variceal: endoscopic haemostasis + IV PPI (omeprazole 80 mg bolus then 8 mg/h infusion for 72 h post-haemostasis)
- Variceal: terlipressin 2 mg IV QDS + prophylactic antibiotics + urgent endoscopic band ligation
Overview
Upper GI bleeding is haemorrhage from the oesophagus, stomach, or duodenum (proximal to the ligament of Treitz). The commonest cause is peptic ulcer disease (~35–50%), followed by oesophago-gastric varices (~10–20% — secondary to portal hypertension), Mallory-Weiss tear (~5–10%), oesophagitis, gastric erosions, and malignancy. Variceal bleeds carry a much higher mortality (~15–20% per episode) than non-variceal causes (~5–10%).
Epidemiology
Upper GI bleeding accounts for approximately 50,000–70,000 hospital admissions per year in the UK. Overall mortality is approximately 7–10%. Incidence increases with age and is more common in males. Key risk factors include NSAID/aspirin use, anticoagulants, H. pylori infection, chronic liver disease, and alcohol excess. Variceal bleeding accounts for a disproportionate share of mortality.
Clinical Features
Symptoms
Haematemesis: fresh red blood (active bleed) or "coffee-ground" vomitus (partially digested blood)
Melaena: black, tarry, offensive-smelling stool (digested blood from upper GI tract)
Dizziness, presyncope, or syncope (hypovolaemia)
Epigastric or abdominal pain
Dysphagia or weight loss (suggests malignancy)
History of liver disease, varices, or heavy alcohol use
Signs
Tachycardia and hypotension (hypovolaemic shock)
Pallor and cold peripheries
Melaena on digital rectal examination
Signs of chronic liver disease: jaundice, spider naevi, palmar erythema, ascites, splenomegaly, caput medusae
Epigastric tenderness
Raised JVP and peripheral oedema (rare — if massive transfusion overload)
Investigations
First-line
Glasgow-Blatchford score (GBS)Pre-endoscopy risk assessment. GBS 0 = very low risk (consider outpatient OGD). Uses Hb, urea, systolic BP, heart rate, melaena, syncope, liver disease, heart failure
FBC, U&Es, LFTs, coagulation screen, group and save (or crossmatch)Urea disproportionately raised relative to creatinine (digested blood = protein load). Check Hb (may be initially normal in acute bleed)
VBG/ABGLactate (tissue perfusion marker), base excess
Second-line
Urgent upper GI endoscopy (OGD)Within 24 hours of presentation. Within 2 hours if suspected variceal bleed or haemodynamically unstable after resuscitation. Diagnostic and therapeutic
Rockall scorePost-endoscopy risk score (uses age, shock, comorbidity, diagnosis, endoscopic stigmata) — guides ongoing management and predicts rebleed/mortality risk
Specialist
CT mesenteric angiographyIf endoscopy fails to identify or control bleeding source — can guide embolisation
Interventional radiology (embolisation)For refractory non-variceal bleeding uncontrolled by endoscopy
TIPSS (transjugular intrahepatic portosystemic shunt)For refractory variceal bleeding not controlled by endoscopic and pharmacological measures
1
Resuscitation
- ABCDE approach with wide-bore IV access (2 × 14–16 G cannulae)
- Crystalloid resuscitation — avoid over-resuscitation in variceal bleeding (target systolic ~100 mmHg)
- Crossmatch and transfuse if Hb <70 g/L (target 70–90 g/L). Use higher threshold if ACS/haemodynamically unstable
- Correct coagulopathy: fresh frozen plasma if INR >1.5; platelets if <50 × 10⁹/L and actively bleeding
2
Non-variceal bleed (at endoscopy)
- Endoscopic haemostasis: dual therapy (adrenaline injection + thermal/clips) for high-risk stigmata (Forrest Ia–IIb)
- IV PPI post-haemostasis: omeprazole 80 mg IV bolus then 8 mg/h infusion for 72 hours
- Do NOT use IV PPI before endoscopy in place of endoscopy
- Rebleed: repeat OGD with endoscopic therapy → if fails, interventional radiology or surgery
3
Suspected variceal bleed
- Terlipressin 2 mg IV QDS (reduce to 1 mg QDS when bleeding controlled) — start before endoscopy
- Prophylactic broad-spectrum antibiotics (e.g. co-amoxiclav or ciprofloxacin) — reduces mortality
- Urgent OGD within 2 hours: endoscopic band ligation (EBL) for oesophageal varices; N-butyl-cyanoacrylate for gastric varices
- Sengstaken-Blakemore tube as temporising measure for life-threatening uncontrolled variceal haemorrhage
- TIPSS for refractory variceal bleeding or early re-bleeding
4
Anticoagulant/antiplatelet management
- Do not stop low-dose aspirin if used for secondary cardiovascular prevention (benefits outweigh risks)
- Warfarin: reverse with IV vitamin K + prothrombin complex concentrate if major bleeding with INR >1.5
- DOACs: consider idarucizumab (for dabigatran) or andexanet alfa (for factor Xa inhibitors) if life-threatening bleeding
Complications
- Rebleeding: ~10–15% within 30 days. Higher risk with Forrest Ia/Ib ulcers and large varices. Most important prognostic factor after initial haemostasis
- Hypovolaemic shock: From massive blood loss — requires aggressive resuscitation
- Aspiration pneumonia: From vomiting blood — maintain airway protection (consider intubation if GCS reduced)
- Hepatorenal syndrome: Precipitated by variceal bleed in cirrhotics
- Death: Overall mortality ~7–10%; variceal bleeding ~15–20% per episode
UKMLA Exam Tips
- 1GBS 0 = very low risk → can be managed as outpatient. GBS ≥1 = admission for endoscopy within 24 hours
- 2Urea is disproportionately raised in upper GI bleed (blood is a protein meal, digested and absorbed → urea production)
- 3Forrest classification for ulcer bleeding: Ia = spurting, Ib = oozing, IIa = visible vessel, IIb = adherent clot, IIc = flat spot, III = clean base
- 4Terlipressin = splanchnic vasoconstrictor. Always give BEFORE endoscopy in suspected variceal bleed (reduces portal pressure)
- 5Band ligation NOT sclerotherapy is the preferred endoscopic treatment for oesophageal varices (lower complication rate)
- 6Transfusion target Hb 70–90 g/L — AVOID over-transfusion in variceal bleeding (raises portal pressure and increases rebleed risk)
practicetest your knowledge on upper gi bleedApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — gastroenterology and beyond.
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