Activate the major haemorrhage protocol if shocked. Use a restrictive transfusion target (Hb 70 g/L, or 80 g/L with cardiovascular disease). Anticoagulants and antiplatelets need a senior plan.
Immediate actions
- Two large-bore cannulae; FBC, U&E, LFTs, coagulation, group and crossmatch
- Restrictive transfusion: Hb target 70 g/L (80 if cardiovascular disease)
- Warfarin with major bleed: prothrombin complex concentrate plus IV vitamin K
- Platelets if below 50 and actively bleeding; keep nil by mouth
Risk scoring
- Glasgow-Blatchford at first assessment (score 0 to 1 may allow outpatient scope)
- Full Rockall after endoscopy for rebleed and mortality risk
- Syncope, melaena, haematemesis, tachycardia, low Hb raise concern
- Known liver disease or stigmata: assume varices
Blatchford 0 to 1 (low)
- Haemodynamically stable
- No melaena or syncope
- Consider outpatient endoscopy
Intermediate
- Admit, IV access, bloods
- Restrictive transfusion Hb 70 (80 if CVD)
- Endoscopy within 24 h
Shock / high risk
- Tachycardia, hypotension, syncope
- Activate major haemorrhage protocol
- Resuscitate then urgent endoscopy
Bleeding pathway
1
1. Resuscitate
ABCDE, oxygen if hypoxic, fluids if hypotensive. Activate major haemorrhage if ongoing major bleed. Restrictive transfusion.
ABCDE, oxygen if hypoxic, fluids if hypotensive. Activate major haemorrhage if ongoing major bleed. Restrictive transfusion.
↓
2
2. Pre-endoscopy
Variceal suspicion: terlipressin plus prophylactic antibiotics (e.g. ceftriaxone). Do not give a PPI before endoscopy for suspected non-variceal bleeding (NICE).
Variceal suspicion: terlipressin plus prophylactic antibiotics (e.g. ceftriaxone). Do not give a PPI before endoscopy for suspected non-variceal bleeding (NICE).
↓
3
3. Endoscopy
Within 24 h of admission, or immediately after resuscitation if unstable. Non-variceal ulcer: adrenaline plus a second method (clips or thermal). Varices: band ligation.
Within 24 h of admission, or immediately after resuscitation if unstable. Non-variceal ulcer: adrenaline plus a second method (clips or thermal). Varices: band ligation.
↓
4
4. Aftercare
IV PPI infusion for high-risk ulcers after endoscopic treatment. H. pylori test and treat. Restart antiplatelet or anticoagulant by MDT decision. Non-selective beta-blocker for varices.
IV PPI infusion for high-risk ulcers after endoscopic treatment. H. pylori test and treat. Restart antiplatelet or anticoagulant by MDT decision. Non-selective beta-blocker for varices.
Variceal suspicion
- Cirrhosis, splenomegaly, ascites
- Terlipressin and antibiotics early
- Consider balloon tamponade if exsanguinating and endoscopy delayed
Pitfalls
- Giving a PPI instead of resuscitating
- Over-transfusing (worsens variceal bleeding)
- Delaying endoscopy in an unstable patient
- Stopping all antithrombotics without a plan
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026