Upper gastrointestinal bleeding initial resuscitation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Upper gastrointestinal bleeding management (initial resuscitation)

Initial management of acute upper gastrointestinal bleeding (UGIB) prioritizes rapid assessment of airway, breathing, and circulation; restoration of intravascular volume and end-organ perfusion; appropriate blood-product support; and stabilization before endoscopy. Initial hemoglobin may underestimate the magnitude of acute blood loss because equilibration between intravascular and extravascular compartments takes time; resuscitation decisions should therefore incorporate hemodynamic status, ongoing bleeding, and the overall clinical picture.

Initial assessment and triage

• Assess airway, breathing, and circulation immediately.
• Determine hemodynamic status using blood pressure, heart rate, mental status, peripheral perfusion, and other evidence of shock or ongoing hemorrhage.
• Patients with hemodynamic instability, active hematemesis, or other evidence of significant hemorrhage require prompt resuscitation and monitoring in an appropriately monitored setting; intensive care unit management may be required for severe or persistent instability.
• Calculate the Glasgow-Blatchford score (GBS) at presentation. Patients with a GBS of 0–1 are at very low risk (≤1% risk of requiring hospital-based intervention or death) and may be considered for discharge with outpatient follow-up rather than hospital admission when clinically appropriate (conditional recommendation, very-low-quality evidence).
• Disposition should also account for hemodynamic status, ongoing bleeding, comorbidities, age, social support, and access to follow-up.
• The AIMS65 score may complement GBS for mortality prognostication. One point is assigned for each of: albumin <3.0 g/dL, international normalized ratio >1.5, altered mental status, systolic blood pressure ≤90 mmHg, and age >65 years. Increasing scores are associated with increasing in-hospital mortality. AIMS65 is primarily a prognostic tool and should not replace GBS for identification of very-low-risk patients suitable for outpatient management.

Airway management

Routine prophylactic endotracheal intubation is not required for all patients with UGIB. Airway protection should be considered in patients with massive or ongoing hematemesis, altered mental status, impaired airway-protective reflexes, or another clinical condition creating a substantial aspiration risk.

If intubation is required in a hemodynamically unstable patient, optimize resuscitation before induction when feasible and anticipate blood and gastric contents in the airway, with adequate suction immediately available.

Vascular access and fluid resuscitation

• Establish two large-bore peripheral intravenous lines; 16-gauge or larger access is appropriate when rapid volume or blood-product administration may be required.
• If adequate peripheral access cannot be obtained during severe hemorrhage, large-bore central venous or intraosseous access may be required.
• Administer isotonic crystalloid, such as normal saline or lactated Ringer's solution, to patients with hemodynamic compromise while blood products are prepared when indicated.
• Titrate crystalloid administration to restoration of adequate perfusion and hemodynamic stability rather than using a fixed resuscitation volume for every patient.
• Monitor vital signs and clinical perfusion; monitor urine output when clinically indicated and obtain serial hemoglobin measurements during ongoing resuscitation.

Red blood cell transfusion

A restrictive red blood cell transfusion strategy is recommended for most patients hospitalized with acute UGIB. The ACG guideline suggests red blood cell transfusion at a hemoglobin threshold of 7 g/dL in most patients.

In the randomized Villanueva et al. trial (n=921), a restrictive transfusion strategy using a hemoglobin threshold of 7 g/dL was compared with a liberal threshold of 9 g/dL. Restrictive transfusion was associated with higher 6-week survival (95% vs. 91%; hazard ratio for death 0.55, 95% CI 0.33–0.92) and lower rebleeding (10% vs. 16%; P=0.01).

The trial did not establish the optimal transfusion strategy for every clinical scenario; transfusion should be individualized in patients with severe ongoing or exsanguinating hemorrhage or active myocardial ischemia.

Clinical setting	Initial transfusion approach
Most patients with acute UGIB	Consider red blood cell transfusion when hemoglobin is <7 g/dL.
Pre-existing cardiovascular disease	A threshold around 8 g/dL may be reasonable; individualize according to cardiovascular status, ischemic risk, and severity of bleeding.
Hemodynamic instability or severe ongoing hemorrhage	Do not delay necessary transfusion solely because measured hemoglobin remains ≥7 g/dL; acute hemoglobin may not yet reflect the full magnitude of blood loss.
Cirrhosis with suspected variceal hemorrhage	A restrictive strategy with a target hemoglobin approximately 7–8 g/dL is generally favored.
Acute coronary syndrome	The optimal transfusion threshold in the setting of acute UGIB remains uncertain; individualize according to myocardial ischemia, hemodynamics, and bleeding severity.

Platelets and coagulation products

Blood-product administration should be guided by the clinical context, severity of ongoing hemorrhage, laboratory evidence of coagulopathy, anticoagulant exposure, and local massive hemorrhage protocols.

• Patients with massive bleeding should receive blood, platelets, and coagulation factors according to the institution's massive hemorrhage protocol.
• Do not routinely transfuse platelets in patients who are not actively bleeding and are hemodynamically stable.
• Offer platelet transfusion to patients who are actively bleeding and have a platelet count <50 × 10⁹/L.
• In actively bleeding patients, fresh frozen plasma may be administered when the prothrombin time, international normalized ratio, or activated partial thromboplastin time is >1.5 times normal.
• If fibrinogen remains <1.5 g/L despite fresh frozen plasma, cryoprecipitate should be administered.
• For life-threatening bleeding associated with warfarin, rapid reversal with 4-factor prothrombin complex concentrate and IV vitamin K is preferred rather than relying on fresh frozen plasma alone.

Immediate pre-endoscopic pharmacotherapy

Proton pump inhibitors

Evidence does not establish a mortality or rebleeding benefit from routine proton pump inhibitor (PPI) administration before endoscopic diagnosis. The ACG 2021 guideline therefore made no recommendation for or against pre-endoscopic PPI therapy. Pre-endoscopic PPI therapy may reduce the proportion of patients requiring endoscopic hemostatic treatment, but it should not delay definitive endoscopic evaluation.

Prokinetic therapy

In selected patients, particularly when substantial blood or clot is expected in the stomach, the ACG conditionally suggests erythromycin 250 mg IV, generally administered 20–90 minutes before endoscopy (conditional recommendation, very-low-quality evidence). Erythromycin can improve gastric emptying and endoscopic visualization and reduce the need for repeat endoscopy, but has not demonstrated a mortality or rebleeding benefit. Use cautiously in patients with significant QT prolongation or other contraindications.

If IV erythromycin is unavailable, the 2026 European Society of Gastrointestinal Endoscopy guideline suggests pre-endoscopic IV metoclopramide in selected patients with clinically severe or ongoing active upper gastrointestinal hemorrhage.

Suspected variceal bleeding

When acute variceal hemorrhage is suspected, vasoactive therapy such as octreotide, somatostatin, or terlipressin should be initiated promptly rather than waiting for endoscopic confirmation.

Patients with cirrhosis presenting with UGIB should receive prophylactic antibiotics from presentation because antibiotic prophylaxis reduces infectious complications and improves clinically important outcomes.

Tranexamic acid

Routine tranexamic acid therapy is not recommended for acute gastrointestinal bleeding. The HALT-IT randomized trial found no reduction in bleeding-related mortality and demonstrated increased venous thromboembolic events with high-dose tranexamic acid.

Management of antithrombotic therapy during resuscitation

Management of anticoagulant and antiplatelet therapy should balance the severity of hemorrhage against the indication for antithrombotic therapy and the patient's thrombotic risk. Reversal or hemostatic agents are generally reserved for life-threatening bleeding or major bleeding that does not respond to initial measures.

Antithrombotic	Initial approach in life-threatening bleeding
Warfarin	Administer 4-factor prothrombin complex concentrate (4F-PCC) for rapid reversal together with IV vitamin K. Fresh frozen plasma may be used if 4F-PCC is unavailable.
Dabigatran	Administer idarucizumab 5 g IV. If unavailable, PCC or activated PCC may be considered.
Factor Xa inhibitors (apixaban, rivaroxaban, edoxaban)	The 2020 ACC pathway recommended andexanet alfa for life-threatening factor Xa inhibitor-associated bleeding, with PCC or activated PCC when andexanet was unavailable. In the United States, commercial sales of andexanet alfa ended on December 22, 2025; current use outside the United States should follow local regulatory guidance and product availability. When clinically appropriate, 4F-PCC may be used for life-threatening bleeding. Activated charcoal may be considered after a known recent factor Xa inhibitor ingestion within 2–4 hours.
Antiplatelet therapy	Avoid reflexive reversal solely because UGIB is present. Management should account for bleeding severity, indication for antiplatelet therapy, and thrombotic risk; specialist input may be appropriate.

Timing of long-term resumption of antithrombotic therapy is outside the scope of initial resuscitation.

Nasogastric tube

Routine nasogastric tube placement or nasogastric lavage is not recommended as part of initial UGIB management. A negative aspirate does not reliably exclude an upper gastrointestinal source, and routine lavage has not demonstrated improvement in major clinical outcomes.

Selective use may be considered when the result is expected to resolve a specific diagnostic or management uncertainty, but nasogastric lavage should not delay resuscitation or definitive evaluation.

Key initial management principles

• Assess airway, breathing, circulation, hemodynamic status, and severity of ongoing hemorrhage.
• Establish large-bore vascular access and begin isotonic crystalloid when required for hemodynamic compromise.
• Use a restrictive red blood cell transfusion strategy in most patients, with a hemoglobin threshold of approximately 7 g/dL; individualize in severe ongoing hemorrhage, cardiovascular disease, or myocardial ischemia.
• Correct clinically important thrombocytopenia or coagulopathy when indicated; do not transfuse platelets routinely in stable patients without active bleeding.
• Protect the airway selectively when aspiration risk or impaired airway protection warrants intubation.
• In suspected variceal hemorrhage, initiate vasoactive therapy promptly; patients with cirrhosis and UGIB should receive antibiotic prophylaxis.
• Consider pre-endoscopic erythromycin when substantial gastric blood or clot is anticipated; IV metoclopramide may be considered in selected severe or ongoing bleeding when erythromycin is unavailable.
• Reverse anticoagulation when life-threatening or uncontrolled bleeding warrants reversal while accounting for thrombotic risk.
• Do not routinely use tranexamic acid or nasogastric lavage.
• Stabilize the patient before definitive endoscopic management.