Acute Upper Gastrointestinal Bleeding — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Hemodynamic assessment & resuscitation
   Is the patient hemodynamically stable? (First assess airway/circulation and resuscitate: two large-bore IV lines, crystalloid, type and cross-match.)
   • Unstable (shock / active major bleed) → Unstable → immediate resuscitation + urgent endoscopy
   • Stable → Glasgow-Blatchford score
2. [End] Unstable → immediate resuscitation + urgent endoscopy
   Aggressive resuscitation: crystalloid + cross-matched blood; restrictive transfusion at Hb <70 g/L (target 70–90; threshold <80 and target ≥100 with cardiovascular disease); correct coagulopathy and weigh stopping antithrombotics (generally do not stop low-dose aspirin for secondary prevention). Endoscopy as early as possible once stabilized (<12 h if variceal suspected, <24 h otherwise). If variceal suspected, start a vasoactive drug (terlipressin/somatostatin/octreotide) + prophylactic antibiotics (ceftriaxone) right away.
3. [Decision] Glasgow-Blatchford score
   GBS score? (GBS includes hemoglobin, SBP, urea, heart rate, melena, syncope, liver disease, heart failure. GBS ≤1 is very low risk; at GBS ≥6, >50% need intervention.)
   • GBS 0–1 (very low risk) → Very low risk → outpatient
   • GBS ≥2 → Admit · identify the bleeding source
4. [End] Very low risk → outpatient
   Very low risk (GBS 0–1, <1% risk of intervention/death): usually no admission needed; arrange outpatient endoscopy and follow-up with safety-net and return advice.
5. [Decision] Admit · identify the bleeding source
   Variceal bleeding suspected (cirrhosis / portal hypertension)?
   • Variceal suspected (cirrhosis / portal HTN) → Variceal bleeding
   • Non-variceal (ulcer etc. suspected) → Non-variceal (mostly peptic ulcer)
6. [End] Variceal bleeding
   Early vasoactive drug (terlipressin/somatostatin/octreotide) + prophylactic antibiotics (ceftriaxone); endoscopic band ligation (or sclerotherapy) ideally <12 h (within 24 h); consider TIPS for uncontrolled bleeding, with a balloon tamponade tube as a bridge if needed. Restrictive transfusion, correct coagulopathy, monitor.
7. [End] Non-variceal (mostly peptic ulcer)
   IV PPI; endoscopy within 24 h; for high-risk stigmata (active bleeding, visible vessel) perform endoscopic hemostasis (clip/thermal/injection) + high-dose PPI afterward; test for and eradicate H. pylori; assess rebleeding risk. Restrictive transfusion at Hb <70 g/L.

Source guidelines & references

• ACG 2021 Clinical Guideline: Upper GI and ulcer bleeding. Am J Gastroenterol 2021
• ESGE 2021 Non-variceal upper GI hemorrhage guideline (update). Endoscopy 2021;53:300 · source ↗

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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