Upper gastrointestinal bleeding

Manage now— do this, in order

• Position and protect the airway first: sit the conscious patient up, put the obtunded patient in the left lateral position, keep suction to hand — aspiration, not exsanguination, is the commonest preventable death. Consider tracheal intubation before endoscopy in repeated recent haematemesis, suspected variceal haemorrhage, reduced consciousness, or any plan for balloon tamponade. Oxygen to saturations 94–98%, high-flow via reservoir mask in shock.
• Two large-bore IV cannulae, 16 gauge or larger; nothing by mouth until endoscopy. Fluids: 500 mL crystalloid bolus over less than 15 minutes in an unstable adult, reassessing after every bolus — avoid indiscriminate large-volume crystalloid (dilutional coagulopathy, hypothermia, worse ascites in cirrhosis). Shocked child: 10 mL/kg boluses of 0.9% sodium chloride; if still shocked after 20 mL/kg, packed red cells 10 mL/kg.Doctor / Nurse
• Transfuse to physiology, restrictive by default: below 70 g/L for most, below 90 g/L in high-risk patients (elderly, coronary artery disease), and a target of 80 g/L in cirrhosis — over-transfusion raises portal pressure and provokes early rebleeding. A hypovolaemic patient with a normal haemoglobin may still need blood.Doctor / NurseNot available at your setup — Blood & blood products.
• Correct coagulopathy in parallel: platelets if below 50 × 10⁹/L with active bleeding; fresh frozen plasma if fibrinogen below 1 g/L or PT/INR or APTT over 1.5 times normal; prothrombin complex concentrate plus vitamin K (phytomenadione) 5–10 mg slow IV for the actively bleeding warfarinised patient, rechecking the INR. Stop any direct oral anticoagulant and record the time of the last dose.Doctor / NurseNot available at your setup — Blood & blood products, Coagulation (PT/INR).
• Give a proton pump inhibitor to every upper GI bleed before the cause is known: pantoprazole, omeprazole or esomeprazole 40 mg IV twice daily; paediatric omeprazole or pantoprazole 1 mg/kg IV once daily, maximum 40 mg.Doctor / Nurse
• If the bleeding may be variceal, give the vasoactive drug immediately, before endoscopy: terlipressin 2 mg IV every 6 hours until bleeding stops, then 1 mg every 4–6 hours, up to 72 hours — the only vasoconstrictor proven to reduce mortality; contraindicated in ischaemic heart disease, and check the serum sodium (hyponatraemia).Doctor / Nurse
• Antibiotic prophylaxis is mandatory in cirrhosis and improves survival: ceftriaxone 1 g IV once daily, stepping down to ciprofloxacin 500 mg orally 12-hourly when eating, total course 5–7 days (children ceftriaxone 50 mg/kg IV once daily; cefotaxime 50 mg/kg IV 8-hourly in a neonate under 28 days on calcium-containing fluids or jaundiced). Add lactulose 10–30 mL three times daily titrated to two soft stools, and IV thiamine before glucose in any alcohol history.Doctor / Nurse
• Endoscopy after adequate resuscitation, ideally within 24 hours — immediately after resuscitation if unstable. In severe bleeding clear the stomach first: erythromycin 3 mg/kg IV over 20 minutes or metoclopramide 10 mg IV, 30–90 minutes beforehand. Band ligation for oesophageal varices, cyanoacrylate glue for gastric varices, dilute adrenaline combined with thermal coagulation or clipping for high-risk ulcers (adrenaline alone is insufficient). After a high-risk ulcer: PPI 80 mg IV bolus then 8 mg/hour for 72 hours.Doctor / NurseNot available at your setup — Infusion pump.
• Monitor hourly — rebleeding declares itself as a rising pulse before anything else. Do not give tranexamic acid reflexively (HALT-IT: no mortality benefit, excess venous thromboembolism and seizures). If first-line treatment fails, repeat endoscopy once; balloon tamponade is a bridge only — intubate first, inflate the gastric balloon with 200–250 mL of air (never without confirming position — oesophageal inflation causes rupture), maximum 12 hours in place.Doctor / Nurse