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]


In patients with acute upper GI bleeding who are unstable rapid assessment and resuscitation should be initiated even before diagnostic evaluation. The initial steps in the management of a patient with UGIB is to assess the severity of bleeding, and then institute fluid and blood resuscitation as needed. Once hemodynamic stability is achieved, a proper clinical history, physical examination, and initial laboratory findings are crucial not only in determining the likely sources of bleeding but also in directing the appropriate intervention. Equilibration between the intravascular and extravascular volumes cannot be achieved until 24 to 72 hours after bleeding has occurred. Nasogastric lavage should be performed if the presence or source of bleeding is unknown. Upper gastrointestinal endoscopy is the primary diagnostic tool, performed for both diagnosis and treatment of active bleeding. The American Society for Gastrointestinal Endoscopy guidelines recommends upper endoscopy within 24 hours of presentation in all patients with UGIB. Angiography and tagged erythrocyte scan are rarely needed but may be used to diagnose active UGIB, particularly in patients where EGD is contraindicated. Also, upper gastrointestinal tract radiographic studies using barium are generally not advised, as they may obscure visualization during EGD.

Initial Management

Management of upper GI bleeding includes:[1][2][3]

Initial resuscitation

  • The initial steps in the management of a patient with UGIB is to assess the severity of bleeding, and then institute fluid and blood resuscitation as needed.[4][5][6]
  • Any patient with hemodynamic instability or who is actively bleeding should be admitted to the ICU for monitoring and resuscitation
  • The patient’s hemodynamic status is of great importance in determining the degree of severity and triage status.
Criteria for
Admission of patient
  • Age >60yr
  • Transfusion required.
  • Initial Sys BP < 100.
  • Red blood in NG lavage.
  • History of cirrhosis or ascites on examination.

Supportive Therapy

Correlation between physical signs and
the severity of upper gastrointestinal bleeding
Physical signs Bleeding severity
Mild Moderate Severe
Blood loss <1L 1-2L >2L
Systolic blood pressure <120 100-119 <99
Orthostasis - - +
Tachycardia <100 101-120 >140
Skin Warm, well perfused Diaphoretic Cool–cold, clammy
Urine output(ml/hour) >25 10-25 Negligible
Respiratory rate 14-20 20-30 >35
Sensorium Alert Anxious Confused/Drowsy

Blood transfusion

Indications for transfusion

Based on the patient’s age and presence of comorbid conditions.

AGE Target Hematocrit
Elderly patient ( >45) 30%
Younger patient (<45) 25%
patients with portal hypertension 28%
Initial Resuscitation
Initial Evaluation
  • Airway Breathing, Circulation
Supportive Therapy
  • Ensure patent and protected airway.
  • 2 large-bore, peripheral intravenous lines.
Blood transfusion
  • Resuscitate with 1:1:1 of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) to platelets.
  • Consider massive transfusion protocol.
  • Resuscitate to a target hemoglobin of 7 mg/dL.
  • Consider Sengstaken-Blakemore tube for control of immediately life-threatening upper GI bleeding.

National Institute for Health and Care Excellence (NICE) guidline

The National Institute for Health and Care Excellence (NICE) guidline on blood product management in upper GI bleeding:[9]

  • Platelets should only be given if the patient is actively bleeding or hemodynamically unstable and has a platelet count of <50×109/L.
  • Fresh frozen plasma should be given if the fibrinogen level is <1 g/L or the prothrombin time (PT) or activated partial thromboplastin time is >1.5 times normal.
  • Prothrombin complex should be provided to those on warfarin and actively bleeding.
  • Recombinant factor VIIa should only be used when all of the above measures have failed.
Acute GI bleeding
Initial evaluation and resuscitation
Uppe GI endoscopy
Source found
Specific Treatment
Urgent CT
Repeat Endoscopy/Angiograpghy
No source identified
Endoscopic intervention


Upper GI bleeding. Adapted from ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding


  1. Beales I (2017). "Recent advances in the management of peptic ulcer bleeding". F1000Res. 6: 1763. doi:10.12688/f1000research.11286.1. PMC 5621101. PMID 29043071.
  2. Bethea ED, Travis AC, Saltzman JR (2014). "Initial assessment and management of patients with nonvariceal upper gastrointestinal bleeding". J. Clin. Gastroenterol. 48 (10): 823–9. doi:10.1097/MCG.0000000000000194. PMID 25090451.
  3. Klein A, Gralnek IM (2015). "Acute, nonvariceal upper gastrointestinal bleeding". Curr Opin Crit Care. 21 (2): 154–62. doi:10.1097/MCC.0000000000000185. PMID 25692808.
  4. Wassef W (2004). "Upper gastrointestinal bleeding". Curr. Opin. Gastroenterol. 20 (6): 538–45. PMID 15703679.
  5. Kovacs TO (2008). "Management of upper gastrointestinal bleeding". Curr Gastroenterol Rep. 10 (6): 535–42. PMID 19006607.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, Rotondano G, Hucl T, Dinis-Ribeiro M, Marmo R, Racz I, Arezzo A, Hoffmann RT, Lesur G, de Franchis R, Aabakken L, Veitch A, Radaelli F, Salgueiro P, Cardoso R, Maia L, Zullo A, Cipolletta L, Hassan C (2015). "Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline". Endoscopy. 47 (10): a1–46. doi:10.1055/s-0034-1393172. PMID 26417980.
  7. Al-Jaghbeer M, Yende S (2013). "Blood transfusion for upper gastrointestinal bleeding: is less more again?". Crit Care. 17 (5): 325. doi:10.1186/cc13020. PMC 4056793. PMID 24063362.
  8. Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C (2013). "Transfusion strategies for acute upper gastrointestinal bleeding". N. Engl. J. Med. 368 (1): 11–21. doi:10.1056/NEJMoa1211801. PMID 23281973.
  9. "Acute upper gastrointestinal bleeding in over 16s: management | Guidance and guidelines | NICE".
  10. Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI (2021) ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol 116 (5):899-917. DOI:10.14309/ajg.0000000000001245 PMID: 33929377