START: Suspected UGIB
Hematemesis, melena, or coffee-ground emesis
All Pathways
Emergency MedicineEmergency
Upper GI Bleeding Management (ACG 2021)
Upper GI Bleeding Management (ACG 2021): START: Suspected UGIB → Initial Resuscitation → Hemodynamically Stable? → Aggressive Resuscitation → IV PPI The...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Action Initial Resuscitation
Stabilize before risk stratification
- 2 large-bore IVs (≥18G)
- Type and screen/crossmatch
- CBC, BMP, coags, LFTs
- NPO status
- Continuous monitoring
03Decision Hemodynamically Stable?
Assess vital signs and perfusion
- UNSTABLE: SBP <90, HR >100, orthostatic changes, signs of shock
- STABLE: Normal vitals, no orthostatic changes
04Warning Aggressive Resuscitation
Hemodynamic instability
- Crystalloid bolus
- Blood transfusion (target Hgb ≥7, or ≥8 if CAD)
- Consider massive transfusion protocol if ongoing bleeding
- Correct coagulopathy (FFP if INR >1.5, platelets if <50K)
- Early GI and surgical consult
05Action IV PPI Therapy
Start before endoscopy
- IV PPI bolus: Pantoprazole 80mg or equivalent
- Followed by continuous infusion 8mg/hr (for high-risk stigmata)
- OR intermittent high-dose (80mg q12h) if low-risk stigmata
- Continue until endoscopy determines risk
06Action Consider Erythromycin
Prokinetic before EGD
- Erythromycin 250mg IV 20-90 min before EGD
- Improves visualization
- Reduces need for repeat endoscopy
- Conditional recommendation
07Decision EGD Timing
Based on stability and risk
- URGENT (<12 hr): Hemodynamically unstable, ongoing bleeding
- EARLY (12-24 hr): High-risk patients (GBS ≥12, liver disease)
- STANDARD (<24 hr): All other admitted patients
08Action Upper Endoscopy (EGD)
Diagnostic and therapeutic
- Identify bleeding source
- Forrest classification for ulcers
- Endoscopic therapy if high-risk stigmata
- Combination therapy preferred (epinephrine + thermal/clip)
09Decision Forrest Classification
Ulcer stigmata risk
- HIGH-RISK (treat): Ia (spurting), Ib (oozing), IIa (visible vessel), IIb (adherent clot)
- LOW-RISK (no treatment): IIc (flat spot), III (clean base)
10Action High-Risk Stigmata
Endoscopic therapy required
- Combination therapy: Epinephrine injection + thermal/clips
- High-dose IV PPI infusion x 72 hours post-EGD
- NPO initially, advance diet as tolerated
- Monitor for rebleeding
11Warning Rebleeding?
Signs of recurrent hemorrhage
- Hematemesis or melena recurrence
- Hemoglobin drop >2g despite transfusion
- Hemodynamic instability
12Action Repeat EGD vs IR/Surgery
Manage rebleeding
- Repeat EGD for second attempt at hemostasis
- Interventional radiology (angioembolization) if EGD fails
- Surgery if IR unavailable or fails
13Outcome Discharge Planning
After successful management
- Test and treat H. pylori if ulcer
- Review and stop NSAIDs if possible
- PPI for 8-12 weeks (longer if on anticoagulation)
- GI follow-up
- Discuss anticoagulation/antiplatelet resumption with cardiology
14Action Low-Risk Stigmata
Medical management
- No endoscopic therapy needed for IIc/III
- Oral PPI daily
- Early feeding (within 24 hr)
- Early discharge if stable
- Path rejoins step 13Shared downstream outcome
15Action Risk Stratification
Calculate Glasgow-Blatchford Score (GBS)
- BUN, Hemoglobin, SBP, HR, Melena, Syncope, Liver disease, Heart failure
- GBS = 0-1: Very low risk, may consider outpatient management
- GBS ≥1: Admit for inpatient management
16Decision GBS 0-1?
Very low risk patients
17Outcome Consider Outpatient EGD
GBS 0-1 may be discharged
- Oral PPI twice daily
- EGD within 24-72 hours as outpatient
- Clear return precautions
- Reliable patient with good support
- Path rejoins step 05Shared downstream outcome
Guideline Source
ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address variceal bleeding in detail (separate algorithm)
- Risk scores should be calculated formally
- Endoscopy timing varies by local resources
- PPI dosing may vary by institution
- Transfusion triggers are general - individualize for comorbidities
Contraindicated Populations
pediatric
Applicable Regions
USEUGlobal
EU: ESGE guidelines are similar, minor differences in PPI dosing
US: ACG is primary US guideline
Version 1Next review: 2028-01-01
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Related Resources
Frequently Asked Questions
What is the Upper GI Bleeding Management (ACG 2021)?
The Upper GI Bleeding Management (ACG 2021) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding.
What guideline is the Upper GI Bleeding Management (ACG 2021) based on?
This algorithm is based on ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding (DOI: 10.14309/ajg.0000000000001529).
What are the limitations of the Upper GI Bleeding Management (ACG 2021)?
Known limitations include: Does not address variceal bleeding in detail (separate algorithm); Risk scores should be calculated formally; Endoscopy timing varies by local resources; PPI dosing may vary by institution; Transfusion triggers are general - individualize for comorbidities. Individual patient factors may require deviation from these recommendations.
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