Intended for healthcare professionals

Practice Practice Pointer

Acute upper gastrointestinal bleeding

BMJ 2018; 363 doi: (Published 25 October 2018) Cite this as: BMJ 2018;363:k4023
cropped thumbnail of infographic

Infographic available

This visual summary presents a practical approach to initial management of patients with upper gastrointestinal bleeding

  1. Emma Sverdén, upper gastrointestinal surgeon1 2,
  2. Sheraz R Markar, upper gastrointestinal surgeon, lecturer1 3,
  3. Lars Agreus, general practitioner, professor4 5,
  4. Jesper Lagergren, upper gastrointestinal surgeon, professor1 6
  1. 1Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
  2. 2Department of Upper Gastrointestinal Surgery, South Hospital, Stockholm, Sweden
  3. 3Department of Surgery and Cancer, Imperial College, London, UK
  4. 4Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
  5. 5University of Newcastle, Australia
  6. 6School of Cancer and Pharmaceutical Sciences, King’s College London, and Guy’s and St Thomas’ NHS Foundation Trust, UK
  1. Correspondence to E Sverden emma.s.eklund{at}

What you need to know

  • Acute upper gastrointestinal bleeding is a medical emergency, and appropriate initial resuscitation is crucial

  • A normal haemoglobin value and blood pressure at presentation does not rule out substantial bleeding—increased heart rate is a more reliable measure of substantial blood loss

  • The Glasgow-Blatchford score can help identify patients for whom outpatient care is suitable

  • Aim for a haemoglobin level of 70-90 g/L for those without cardiac problems

Bleeding from the upper gastrointestinal tract (oesophagus, stomach, and duodenum) occurs in approximately 100 per 100 000 people annually.12 It is a medical emergency associated with substantial mortality. A UK audit in 2007 found an overall mortality of 10%.3 This practice pointer provides a guide to the initial management of upper gastrointestinal bleeding and subsequent management of bleeding that results from peptic ulceration, the most common cause (box 1).6

Box 1

Causes of upper gastrointestinal bleeding45

  • Peptic ulcer (31%-67%)

  • Gastritis or duodenitis (7%-31%)

  • Variceal bleeding (4%-20%)

  • Erosive oesophagitis (3%-12%)

  • Mallory-Weiss tear (4%-8%)

  • Tumours (2%-8%)

  • Aorto-enteric fistulas, arteriovenous malformations, or Dieulafoy’s lesions (2%-8%)


How might you manage patients initially?

Assessment and resuscitation

Patients may present with melaena, vomiting fresh blood, or with “coffee ground” vomiting (vomit can take on the appearance of coffee grounds when blood reacts with hydrochloric acid in the stomach). Abdominal pain may also be present. Fresh per rectal bleeding (haematochezia) can occur in major brisk bleeding.7

Assess the patient’s haemodynamic status. Look for visible signs of bleeding. Begin resuscitation in parallel with further clinical assessment. An approach to the initial management of patients with upper gastrointestinal bleeding is shown in the infographic. Early assessment by the intensive care team is recommended in the unstable patient, or where there is airway compromise (such as from haematemesis) or reduced level of consciousness.2 Obtain a medical history alongside a physical examination. Monitor physiological observations including heart rate, blood pressure, respiratory rate, oxygen saturation, and …

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