Intended for healthcare professionals

Clinical Review State of the Art Review

Management of acute upper gastrointestinal bleeding

BMJ 2019; 364 doi: (Published 25 March 2019) Cite this as: BMJ 2019;364:l536
  1. Adrian J Stanley, consultant gastroenterologist and honorary professor1,
  2. Loren Laine, professor of medicine2
  1. 1Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 OSF, UK
  2. 2Section of Digestive Diseases, Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Connecticut, CT 06520, USA
  1. Correspondence to:A J Stanley adrian.stanley{at} and adrianstanley99{at}


Upper gastrointestinal bleeding (UGIB) is a common medical emergency, with a reported mortality of 2-10%. Patients identified as being at very low risk of either needing an intervention or death can be managed as outpatients. For all other patients, intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/L are recommended. After resuscitation is initiated, proton pump inhibitors (PPIs) and the prokinetic agent erythromycin may be administered, with antibiotics and vasoactive drugs recommended in patients who have cirrhosis. Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk, such as those with hemodynamic instability. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices) and for high risk non-variceal bleeding (for example, injection, thermal probes, or clips for lesions with active bleeding or non-bleeding visible vessel). Patients who require endoscopic therapy for ulcer bleeding should receive high dose proton pump inhibitors after endoscopy, whereas those who have variceal bleeding should continue taking antibiotics and vasoactive drugs. Recurrent ulcer bleeding is treated with repeat endoscopic therapy, with subsequent bleeding managed by interventional radiology or surgery. Recurrent variceal bleeding is generally treated with transjugular intrahepatic portosystemic shunt. In patients who require antithrombotic agents, outcomes appear to be better when these drugs are reintroduced early.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: Both authors contributed equally to the planning and writing of the article and both are responsible for the overall content as guarantors.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: AJS, none; LL has had single consultancies to Takeda and to Bayer and his full competing interests are available from her on request.

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