GI bleeding and abdominal emergencies

Non-variceal UGIB and Glasgow-Blatchford

Reviewed Nov 2026·5 references
New· views rounded down, updated weekly

Risk-stratify with Glasgow-Blatchford, resuscitate, give PPI, time endoscopy, and manage rebleeding and anticoagulants.

Definition
Non-variceal UGIB is mostly peptic ulcer (H. pylori, NSAIDs/aspirin), erosive disease, Mallory-Weiss, malignancy, Dieulafoy. Glasgow-Blatchford score (GBS) 0-1 = very low risk (outpatient management possible).

At the bedside

Timed steps
  1. 1

    Assess and resuscitate

    0 min

    Haemodynamics, shock index, Hb, urea, INR, cross-match. Restrictive transfusion: Hb ≤ 7 g/dL (target 7-9); Hb ≤ 8 (target ≥ 10) with cardiovascular disease.

  2. 2

    Calculate GBS

    Blood urea, Hb, SBP, pulse ≥ 100, melaena, syncope, hepatic disease, cardiac failure. GBS ≤ 1: consider outpatient endoscopy. Higher scores: admit.

  3. 3

    PPI

    High-dose IV PPI (pantoprazole 80 mg bolus) before endoscopy; do not delay endoscopy for it.

  4. 4

    Anticoagulants and antiplatelets

    Hold anticoagulants; reverse if life-threatening (vitamin K + PCC for warfarin; idarucizumab for dabigatran; PCC/andexanet for Xa inhibitors). Continue aspirin for secondary prevention if possible; discuss DAPT with cardiology.

  5. 5

    Endoscopy within 24 h

    ≤ 24 h

    After resuscitation, within 24 h. Very early endoscopy (< 6-12 h) did not improve outcome in high-risk patients (Lau 2020) unless unstable despite resuscitation.

  6. 6

    Post-endoscopy

    High-risk stigmata (Forrest Ia, Ib, IIa, IIb) treated endoscopically: high-dose PPI for 72 h (continuous or intermittent 40 mg BD), then oral BD to 2 weeks; test and treat H. pylori.

  7. 7

    Rebleeding

    Repeat endoscopy; if fails: transcatheter arterial embolisation (TAE) or surgery.

  8. 8

    Do not use TXA

    HALT-IT: high-dose TXA did not reduce death and increased venous thromboembolism.

Ulcer bleeding

Pantoprazole (or esomeprazole)

IV
Dose
80 mg bolus, then 8 mg/h for 72 h (or 40 mg IV BD) after endotherapy
Preparation
80 mg in 100 mL NS = 0.8 mg/mL
Worked example
8 mg/h = 10 mL/h
Open infusion calculator

Glasgow-Blatchford score

VariablePoints
Urea 6.5-7.9 mmol/L (urea 39-47 mg/dL; BUN 18-22 mg/dL)2
Urea 8-9.9 mmol/L (urea 48-59 mg/dL; BUN 22-27 mg/dL)3
Urea 10-25 mmol/L (urea 60-150 mg/dL; BUN 28-70 mg/dL)4
Urea > 25 mmol/L (urea > 150 mg/dL; BUN > 70 mg/dL)6
Hb men 12-13 g/dL1
Hb men 10-123
Hb women 10-121
Hb < 10 (either sex)6
SBP 100-109 mmHg1
SBP 90-992
SBP < 903
Pulse ≥ 100/min1
Melaena1
Syncope2
Hepatic disease2
Cardiac failure2

Original score uses blood urea in mmol/L. Indian labs usually report urea in mg/dL (mmol/L × 6); US labs report BUN (mmol/L × 2.8). Use the matching column.

Red flag · call your senior now
Shock index > 1, haematemesis of fresh blood, or Hb drop ≥ 2 g/dL: high-risk bleed - ICU/HDU, early endoscopy after resuscitation.
Pitfall
Delaying resuscitation for endoscopy, or endoscoping an unresuscitated patient.
Pitfall
Stopping aspirin permanently in a patient with coronary stents: thrombosis risk; restart early (often within 3-5 days) after discussion.
Pearl
Forrest classification: Ia spurting, Ib oozing, IIa visible vessel, IIb adherent clot, IIc flat spot, III clean base.

Calculators for this topic

Shock index

Heart rate ÷ systolic BP.

Infusion rate from a fixed hourly or per-minute dose

Pump rate for non-weight-based infusions such as vasopressin (U/min), labetalol (mg/min) or amiodarone (mg/h).

References

  1. 1

    Gralnek IM, Stanley AJ, Morris AJ, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): ESGE Guideline - Update 2021. Endoscopy 2021;53:300-32.

  2. 2

    Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol 2021;116:899-917.

  3. 3

    Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000;356:1318-21.

  4. 4

    Lau JYW, Yu Y, Tang RSY, et al. Timing of endoscopy for acute upper gastrointestinal bleeding. N Engl J Med 2020;382:1299-308.

  5. 5

    HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT). Lancet 2020;395:1927-36.

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