Version July 2025
| Major causes* |
| Peptic ulcer, esophagogastric varices, angiodysplasias, tumor, esophageal (Mallory-Weiss) tear |
| Clinical features |
| History |
| Use of: NSAIDs, aspirin, anticoagulants, antiplatelet agents |
| Alcohol abuse, previous GI bleed, liver disease, coagulopathy |
| Symptoms and signs: Abdominal pain, hematemesis or "coffee ground" emesis, passing melena/tarry stool (stool may be frankly bloody or maroon with massive or brisk upper GI bleeding) |
| Examination |
| Tachycardia; orthostatic blood pressure changes suggest moderate to severe blood loss; hypotension suggests life-threatening blood loss (hypotension may be late finding in healthy younger adults and older adults with hypertension at baseline may be normotensive but have evidence of hypoperfusion) |
| Examination of stool color (melena versus hematochezia versus brown) may provide a clue to the location of the bleeding, but is not a reliable indicator |
| Significant abdominal tenderness accompanied by signs of peritoneal irritation (eg, involuntary guarding) suggests perforation |
| Diagnostic testing |
| Obtain type and crossmatch for hemodynamic instability, severe bleeding, or high-risk patient; obtain type and screen for hemodynamically stable patient without signs of severe bleeding |
| Obtain hemoglobin (note that measurement may be inaccurate with acute severe hemorrhage), platelet count, coagulation studies (prothrombin time with INR), liver enzymes (AST, ALT), albumin, BUN, and creatinine |
| Treatment |
| Closely monitor airway, clinical status, vital signs, cardiac rhythm, urine output, nasogastric output (if nasogastric tube in place) |
| Do not give patient anything by mouth |
| Establish two large bore IV lines (16 gauge or larger) |
| Provide supplemental oxygen (goal oxygen saturation ≥94% for patients without COPD) |
| Treat hypotension initially with rapid, bolus infusions of isotonic crystalloid (eg, 500 to 1000 mL per bolus; use smaller boluses and lower total volumes for patients with compromised cardiac function) |
| Transfusion: |
| For severe, ongoing bleeding, immediately transfuse blood products in 1:1:1 ratio of RBCs, plasma, and platelets, as for trauma patients |
| For hemodynamic instability despite crystalloid resuscitation, transfuse 1 to 2 units RBCs |
| For hemoglobin <9 to 10 g/dL (90 to 100 g/L) in patients with acute coronary syndrome and evidence of hypovolemia and/or ongoing cardiac ischemia, transfuse 1 unit RBCs and reassess the patient's clinical condition |
| For hemoglobin <8 g/dL (80 g/L) in patients with pre-existing or acute coronary artery disease without active bleeding or ongoing ischemia¶, transfuse 1 unit RBCs and reassess the patient's clinical condition |
| For hemoglobin <7 g/dL (70 g/L) in all other patients, transfuse 1 units RBCs and reassess the patient's clinical condition |
| Avoid over-transfusion with possible upper GI bleeding |
| Give platelets for thrombocytopenia (platelets <50,000) |
| Reversal of anticoagulation may be appropriate for some patients: |
| For patients taking warfarin, prothrombin complex concentrate may be appropriate if serious bleeding or markedly supratherapeutic INR |
| For patients taking a DOAC, a specific reversal agent (ie, andexanet alfa or idarucizumab) or prothrombin complex concentrate may be appropriate, but only for life-threatening bleeding |
| Obtain immediate consultation with gastroenterologist; obtain surgical and interventional radiology consultation for any large-scale bleedingΔ |
| Pharmacotherapy for all patients with severe bleeding: |
| Pre-endoscopic proton pump inhibitor therapy may be started empirically: |
| Esomeprazole or pantoprazole, 80 mg IV |
| If a proton pump inhibitor is being given and endoscopy is performed beyond 12 hours, give second dose of esomeprazole or pantoprazole, 40 mg IV |
| Pharmacotherapy for known or suspected esophagogastric variceal bleeding and/or cirrhosis: |
| Give somatostatin, an analogue (eg, octreotide 50 mcg IV bolus followed by 50 mcg/hour continuous IV infusion), or terlipressin (2 mg IV every 4 hours until bleeding is controlled, then decrease to 1 mg IV every 4 hours) |
| Give an IV antibiotic (eg, ceftriaxone) |
| Give IV erythromycin: 250 mg IV (over 10 to 30 min), 20 to 90 min before endoscopy |
| Balloon tamponade (eg, Sengstaken-Blakemore tube, Minnesota tube, Linton-Nachlas tube) or esophageal stenting (in centers with appropriate expertise) may be performed as a temporizing measure for patients with uncontrollable hemorrhage very likely due to varices; tracheal intubation is necessary if balloon tamponade is employed; ensure proper device placement prior to inflation of the gastric balloon to avoid esophageal rupture (hemostasis is often achieved with inflation of the gastric balloon alone, in which case inflation of the esophageal balloon, if present, is not required) |
COPD: chronic obstructive pulmonary disease; DOAC: direct oral anticoagulant; GI: gastrointestinal; INR: international normalized ratio; AST: aspartate aminotransferase; ALT: alanine aminotransferase; BUN: blood urea nitrogen; INR; international normalized ratio; IV: intravenous; RBC: red blood cells.
* An important but uncommon cause of gastrointestinal hemorrhage is vascular-enteric fistula, typically aortoduodenal fistula related to erosion of a prosthetic aortic graft.
¶ A higher goal hemoglobin level (eg, 10 g/dL [100 g/L) may be appropriate for patients with acute coronary ischemia and risk factors for reinfarction, such as incomplete revascularization or high-risk coronary anatomy (eg, left main, multivessel disease), if they do not have risk factors (eg, heart failure) for transfusion complications.
Δ Minimally invasive techniques to control bleeding include sclerotherapy, embolization, and other vascular occlusion techniques. For patients with massive hemorrhage, resuscitative endovascular balloon occlusion of the aorta (REBOA) can be used to limit blood loss and support perfusion of vital organs until the sites of bleeding can be directly controlled.
