Management of acute upper gastrointestinal bleeding

BMJ. 2019 Mar 25:364:l536. doi: 10.1136/bmj.l536.


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.

Publication types

  • Systematic Review

MeSH terms

  • Anti-Bacterial Agents / therapeutic use*
  • Blood Transfusion
  • Disease Management
  • Endoscopy, Gastrointestinal*
  • Esophageal and Gastric Varices / diagnosis
  • Esophageal and Gastric Varices / therapy*
  • Gastrointestinal Hemorrhage / diagnosis
  • Gastrointestinal Hemorrhage / therapy*
  • Humans
  • Liver Cirrhosis / diagnosis
  • Liver Cirrhosis / therapy*
  • Portasystemic Shunt, Transjugular Intrahepatic
  • Practice Guidelines as Topic
  • Proton Pump Inhibitors / therapeutic use*
  • Resuscitation / methods*
  • Severity of Illness Index


  • Anti-Bacterial Agents
  • Proton Pump Inhibitors