START: Suspected upper GI bleeding (adult)
Haematemesis, coffee-ground vomit or melaena. Adults only; not for children.
All Pathways
Emergency MedicineEmergency
Upper GI Bleeding Management (ACG 2021)
Upper GI Bleeding Management (ACG 2021): START: Suspected upper GI bleeding (adult) → Assess and resuscitate at the same time → On an anticoagulant or a...
Pathway Overview
23 steps
Algorithm Steps
23 total
01Start 02Action Assess and resuscitate at the same time
Adult pathway. Stabilise before risk scoring and endoscopy. Do not give tranexamic acid.
- 2 large-bore IV cannulas (18G or larger); IV crystalloid if hypovolaemic
- Red cells: transfuse if Hb under 70 g/L (under 80 g/L with cardiovascular disease). Shocked patients may need blood sooner
- FBC, UEC (urea), LFTs, coagulation, group and crossmatch
- Nil by mouth; continuous monitoring
- Tranexamic acid: do not give (no fall in deaths, more venous thrombosis)
- Ask about anticoagulants, antiplatelets, NSAIDs, liver disease and alcohol
03Warning On an anticoagulant or antiplatelet? Act before endoscopy
Withhold warfarin, DOACs and non-aspirin antiplatelets while bleeding. Reverse only for life-threatening bleeding. Do not delay endoscopy to correct INR.
- Life-threatening bleeding on warfarin: 4-factor prothrombin complex concentrate (Beriplex in Australia) plus IV vitamin K, not FFP; dose per local protocol
- Life-threatening bleeding on a DOAC taken within 24 h: dabigatran - idarucizumab; apixaban or rivaroxaban - specific reversal agent or PCC where available; get haematology advice
- Aspirin for secondary cardiovascular prevention: do not stop. No routine platelet transfusion for antiplatelet use. Coronary stent: get cardiology advice
04Decision Known or suspected cirrhosis or portal hypertension?
For example known varices, alcohol-related liver disease, ascites, jaundice or signs of chronic liver disease. If yes, treat as variceal bleeding until endoscopy.
- If Yes
05Action Suspected variceal bleed: vasoactive drug and antibiotic now
Start before endoscopy. Manage in ICU or HDU. Endoscopy within 12 h, after resuscitation. Terlipressin: not in pregnancy, unstable angina or recent MI; caution with vascular disease, arrhythmia or hypoxia. If so, use octreotide.
- Octreotide (adult): 50 microgram IV bolus, then 50 microgram/h IV infusion
- OR terlipressin (adult, Australian labelling as terlipressin base): 1.7 mg IV every 4 h; 0.85 mg every 4 h once bleeding is controlled, if weight under 50 kg or if adverse effects; PI limit 48 h in total; monitor sodium
- Antibiotic prophylaxis from admission: ceftriaxone 1 g IV every 24 h (follow local policy). Severe beta-lactam allergy: local alternative
- Transfuse conservatively: target Hb 70-80 g/L; massive bleeding: massive transfusion protocol. No FFP to correct INR
- Intubate before endoscopy if consciousness is altered or haematemesis is ongoing
- Erythromycin 250 mg IV 30-120 min before endoscopy, unless QT prolongation
06Outcome Suspected variceal bleed: continue on the variceal bleeding pathway
Varices at endoscopy: band ligation, continue the vasoactive drug for 2-5 days (terlipressin: Australian PI limit 48 h in total; longer course: specialist advice), continue the antibiotic, stop the PPI. Ulcer or other non-variceal source: use the endoscopy and PPI steps of this pathway and continue the antibiotic.
If No07Decision No cirrhosis: haemodynamically unstable?
Shock or ongoing instability, for example SBP under 90 mmHg, HR over 100/min, poor perfusion or ongoing haematemesis. Beta-blockers or a pacemaker can hide a fast heart rate: judge BP and perfusion too.
- If Yes
- Unstable
08Action Unstable: resuscitate, then endoscopy as soon as resuscitated
Call senior GI, ICU, surgical and interventional radiology teams early. Do not delay endoscopy to correct INR.
- Massive bleeding: activate the local massive transfusion protocol
- Transfuse red cells on clinical grounds; do not wait for Hb under 70 g/L if shocked. Avoid over-transfusion
- Active bleeding with platelets under 50 x 10^9/L: transfuse platelets
- Intubate before endoscopy only for ongoing haematemesis, agitation or encephalopathy
09Action Admitted (GBS 2 or more, or unstable): pre-endoscopy IV PPI optional
It reduces high-risk stigmata at endoscopy but not rebleeding or death. It must not delay endoscopy.
- If used: high-dose IV PPI, for example pantoprazole 80 mg IV
- Adjust PPI after endoscopy to the findings
10Action Erythromycin before endoscopy (adult)
Improves the view and reduces repeat endoscopy. Avoid if the QT interval is prolonged.
- Erythromycin 250 mg IV over 20-30 min, 20-90 min before endoscopy
- Caution: heart disease, low potassium or magnesium, antiarrhythmics, or other QT-prolonging drugs
11Action Endoscopy within 24 h of presentation, after resuscitation
Unstable despite resuscitation: endoscopy immediately after resuscitation.
- All other admitted patients: within 24 h
- Very early endoscopy (under 12 h) does not improve outcomes in stable patients, including GBS 12 or more
- Anticoagulant use or INR alone does not set the timing
12Action Upper endoscopy: find the source and treat it
Classify ulcers by Forrest stage. Other lesions: manage as the endoscopist advises.
- Test for H. pylori at the index endoscopy
- Adrenaline injection only in combination with a second method
13Decision High-risk ulcer stigmata?
High risk: Ia spurting, Ib oozing, IIa visible vessel; IIb adherent clot. Low risk: IIc flat pigmented spot, III clean base.
- If Yes
- Ia, Ib, IIa, IIb
14Action High-risk ulcer (Ia, Ib, IIa, IIb): endoscopic therapy, high-dose PPI
Treat Ia, Ib and IIa endoscopically. IIb adherent clot: consider clot removal and treatment of what lies beneath.
- Endoscopic therapy: thermal (bipolar or heater probe), clips (through-the-scope or over-the-scope) or absolute ethanol injection
- After haemostasis: IV PPI 80 mg bolus, then 8 mg/h for 72 h; or 40 mg 2-4 times a day for 3 days (oral if feasible)
- Then oral PPI twice daily until day 14, then once daily
- IIb clot not treated endoscopically: same high-dose PPI
- No routine second-look endoscopy
15Decision After endoscopic therapy: bleeding persists or recurs?
Bleeding not controlled at endoscopy, or new haematemesis or melaena, shock or a falling Hb after haemostasis.
- If Yes
16Action Bleeding persists or recurs: rescue therapy, call radiology (IR) early
Resuscitate first. Rebleeding after successful haemostasis: repeat endoscopy and endoscopic therapy before surgery or embolisation. Bleeding not controlled by endoscopic therapy: go to embolisation.
- Endoscopic rescue: over-the-scope clip, or topical haemostatic agent for active bleeding
- Endoscopic therapy fails: transcatheter arterial embolisation (TAE)
- TAE not available or fails: surgery
17Outcome Bleeding controlled: high-dose PPI, then discharge planning
Continue the high-dose PPI regimen. Then follow the discharge planning step (H. pylori, NSAIDs, antithrombotics).
If No18Outcome No rebleeding: discharge planning to prevent recurrence
Restart cardiac aspirin early. Agree when to restart anticoagulants. Treat H. pylori, stop NSAIDs, give iron if iron deficient.
- H. pylori: treat if positive; retest if the first test was negative; confirm eradication
- Stop NSAIDs, including COX-2 inhibitors
- PPI: after a high-risk ulcer, twice daily to day 14, then once daily; continue with ongoing antiplatelet or anticoagulant therapy
- Aspirin for secondary prevention: continue; if stopped, restart when haemostasis is confirmed (within 3-5 days)
- Aspirin for primary prevention only: stop and review the need
- Dual antiplatelets: continue aspirin; restart the second agent within 5 days, with cardiology advice
- Anticoagulant: restart once bleeding is controlled, preferably within or soon after 7 days, based on clot risk
- Iron deficiency or anaemia: start iron before discharge
- GI follow-up
If No- IIc, III
19Action Low-risk ulcer (IIc, III): no endoscopic therapy
Standard oral PPI once daily. Selected patients can go home early.
- No endoscopic haemostasis for a flat pigmented spot or clean base
- Early feeding and discharge when stable
- Path rejoins step 18Shared downstream outcome
If No- Stable
20Action Stable: calculate the Glasgow-Blatchford score (GBS)
Use it before endoscopy to find very-low-risk patients.
- Items: urea (mmol/L), Hb (g/L), systolic BP, heart rate, melaena, syncope, liver disease, heart failure
- GBS 0-1: very low risk; outpatient care may be possible
- GBS 2 or more: admit for inpatient endoscopy
21Decision GBS 0 or 1?
Very-low-risk patient
- If Yes
- GBS 0-1
22Outcome GBS 0-1: discharge with outpatient endoscopy
Only if the patient is reliable, has support and has no other reason for admission. Return now if vomiting blood, black stools, dizziness or collapse.
- Arrange outpatient endoscopy
- Stop NSAIDs
If No- GBS 2 or more
23Action GBS 2 or more: admit for inpatient endoscopy
Continue with the pre-endoscopy steps: PPI, erythromycin, then endoscopy within 24 h.
- Path rejoins step 09Shared downstream outcome
Guideline Source
ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding (Laine L et al., Am J Gastroenterol 2021;116:899-917)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Variceal bleeding is covered only for first steps; use the variceal bleeding pathway for full care.
- Guidelines differ on pre-endoscopy PPI (ACG 2021: no recommendation; ESGE 2026: consider; NICE CG141: do not give). Reversal agent doses: follow the local protocol.
- Endoscopic therapy for non-ulcer lesions (for example Mallory-Weiss tear, Dieulafoy lesion, tumour) is not covered.
- Transfusion thresholds are general; individualise for comorbidities and ongoing bleeding.
- Calculate risk scores formally; GBS 0-1 discharge needs reliable follow-up.
Contraindicated Populations
pediatric
Applicable Regions
AUUSEUGlobal
AU: Hb is reported in g/L and urea in mmol/L. Beriplex (4-factor PCC) replaced Prothrombinex-VF for warfarin reversal (MJA 2025). Terlipressin is labelled as base: 1.7 mg every 4 h, course no more than 48 h (TGA PI).
EU: ESGE 2026 peptic ulcer bleeding update: consider pre-endoscopy high-dose IV PPI; no endoscopy within 12 h unless unstable despite resuscitation; over-the-scope clip is a first-line option for Forrest Ia/Ib; iron before discharge.
UK: NICE CG141: consider early discharge at GBS 0; no PPI before endoscopy; endoscopy within 24 h.
US: ACG 2021 is the primary US guideline; ACG-CAG 2022 covers anticoagulants and antiplatelets in GI bleeding.
Version 2Next review: 2027-09-30
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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 (Laine L et al., Am J Gastroenterol 2021;116:899-917).
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 (Laine L et al., Am J Gastroenterol 2021;116:899-917) (DOI: 10.14309/ajg.0000000000001245).
What are the limitations of the Upper GI Bleeding Management (ACG 2021)?
Known limitations include: Adults only. Variceal bleeding is covered only for first steps; use the variceal bleeding pathway for full care.; Guidelines differ on pre-endoscopy PPI (ACG 2021: no recommendation; ESGE 2026: consider; NICE CG141: do not give). Reversal agent doses: follow the local protocol.; Endoscopic therapy for non-ulcer lesions (for example Mallory-Weiss tear, Dieulafoy lesion, tumour) is not covered.; Transfusion thresholds are general; individualise for comorbidities and ongoing bleeding.; Calculate risk scores formally; GBS 0-1 discharge needs reliable follow-up.. Individual patient factors may require deviation from these recommendations.
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