Melena / hematemesis / hematochezia; tachycardia, orthostatic ↓BP
ABCDE 2 large IV, resuscitate, cross-match; airway protection if massive; PPI; urgent endoscopy; variceal bundle.
Calculators: fluid
First — most important: 2 large-bore IV + fluid resuscitation; check orthostatics; transfuse to Hb ≥7 (≥8 if cardiac)
Give: PPI 80 mg IV bolus → 8 mg/h ×72 h only after endoscopic therapy of high-risk ulcer; otherwise twice-daily IV/PO PPI suffices
Then: Upper endoscopy (diagnostic + therapeutic)
If variceal → add Octreotide 50 µg bolus → 50 µg/h + Ceftriaxone 1 g/day → band ligation
Decision tree Haemodynamically unstable?
Yes Resuscitate (2 large IV, blood, massive haemorrhage protocol); airway if massive; urgent endoscopy
No Suspected variceal bleed?
Yes Terlipressin/octreotide + antibiotics → endoscopic band ligation
No PPI; risk score (Glasgow-Blatchford); endoscopy within 24 h
Order set 2 large IV, resuscitate FBC, coags, cross-match U&E (urea) PPI infusion Endoscopy Group & save IV erythromycin 250 mg 30–60 min pre-endoscopy (improves visualization; ACG 2021) Anticoagulant/antiplatelet plan: hold DOAC/warfarin (PCC if life-threatening); continue aspirin for secondary prevention where possible Monitor 0 min 2 large IV; resuscitate; transfuse Hb ≥7; PPI 1 h Reassess vitals + Hb; crossmatch <24 h Upper endoscopy (dx + therapy) Post-scope Watch for rebleed; repeat Hb Escalate / ICU Ongoing bleeding / hemodynamic instability ≥4 units / massive transfusion Variceal bleed needing airway protection Rebleed after endoscopy Criteria Admit All significant GI bleeds
ICU Shock, ongoing bleeding, variceal, rebleed
Intubate Massive haematemesis / airway protection for scope
Vasopressors Only as bridge — priority is haemostasis + blood
Transfuse Hb <70 g/L (restrictive); massive haemorrhage protocol if unstable
Low risk Glasgow-Blatchford score 0–1 → safe for outpatient management
Discharge Haemostasis achieved, Hb stable, no rebleed, cause/plan documented
Clinical detail — differentials, red flags, pitfalls, disposition Red flags Shock Haematemesis with instability Rebleed Differentials Peptic ulcer Varices Mallory-Weiss Malignancy Lower GI source Common mistakes Under-resuscitation Missing variceal cause (no octreotide/antibiotics) Tranexamic acid for GI bleeding — HALT-IT (n=12,009): no mortality benefit, ↑VTE and seizures; do not use Disposition & follow-up Endoscopy within 24 h; ICU if unstable/variceal.
Discharge package Medications PPI; H. pylori eradication if indicated; review anticoagulant/NSAID
Follow-up Endoscopy follow-up; repeat scope for gastric ulcer
Warning symptoms Melaena, haematemesis, dizziness, collapse
💊 Treatment detail — doses & preparation Pantoprazole IV PPI infusion
Dose 80 mg IV bolus then 8 mg/h ×72 h — only after endoscopic therapy of high-risk ulcer stigmata; otherwise BID IV/PO PPI
Preparation 40 mg vial reconstitute; infusion 80 mg in 100 mL NS over protocol, or 8 mg/h via pump
Monitor Rebleeding, Hb; step down to PO 40 mg OD after 72 h
Terlipressin variceal vasoconstrictor
Dose 2 mg IV q4h until bleed controlled, then 1 mg q4h (total ≤5 d)
Preparation 1 mg vial reconstitute with 5 mL diluent; slow IV push
Monitor BP, abdominal cramps, ischaemia (limb/coronary); combine with band ligation
Ceftriaxone 3rd-gen cephalosporin
Dose Variceal bleeding prophylaxis: 1 g IV q24h × up to 7 d (2 g is the meningitis dose — not for this indication); gonorrhoea 500 mg–1 g IM once
Preparation IV: 2 g in 50–100 mL NS over 30 min; IM: reconstitute with lidocaine 1%
Monitor Biliary sludging; avoid with calcium-containing IV fluids in same line
0.9% Sodium chloride crystalloid
Dose Bolus 500 mL over 15–30 min, reassess; maintenance 1–1.5 mL/kg/h
Preparation 500/1000 mL bags; add KCl only after urine output confirmed
Monitor Hyperchloraemic acidosis with large volumes — prefer balanced (LR) for resuscitation
📖 ACG / BSG GI Bleeding Reviewed July 2026