Visual summary

Initial assessment Haemodynamically stable

Check circulatory status
Management of upper to assess need for
immediate interventions
Signs of current bleeding

gastrointestinal bleeding Hematochezia

This visual summary presents a practical approach Blood pressure may remain Haematemesis
to initial management of patients with upper normal initially, so increased
gastrointestinal bleeding. Peptic ulcers are the most heart rate is a more sensitive
common cause of serious bleeding from the measure of circulatory status
oesophagus, stomach, and duodenum, and can Urgent intensive care involvement required for:
be identified with simple diagnostic tests. Haemodynamically unstable
Airway compromise Hypoxia
Reduced level of consciousness

Initial resuscitation
2 x Large bore Urinary catheter
intravenous access (if required)
Actions in
parallel
Obtain blood Obtain medical Intravenous fluids Pharmacological treatment
(proton pump inhibitor)
chemistry history

Risk stratification Glasgow-Blatchford Score (GBS)

Systolic blood pressure Blood urea Haemoglobin

mmHg mmol/L g/dL Pulse ≥ 100 1

100–109 1 6.5 – 7.9 2 Men Women Melaena 1

90 – 99 2 8.0 – 9.9 3 12.0 –12.9 10.0 – 11.9 1 Syncope 2

< 90 3 10.0 – 24.9 4 10.0 –11.9 3 Hepatic disease 2

≥ 25.0 6 < 10.0 < 10.0 6 Cardiac failure 2

Low risk of death. Can be considered Predicts need for endoscopic haemostatic
Total score 0 – 1 5+ Increased risk of 30-day mortality 7+
for outpatient management. intervention, but needs individual evaluation

Total score Total score

0 – 1 2+
Haemodynamically stable Haemodynamically unstable
Endoscopy within 24 hours Emergency endoscopy

Early discharge Proton pump

Endoscopy in inhibitor
outpatient clinic Eradication of any
Helicobacter pylori
Successful haemostasis Not successful haemostasis
infection

Embolisation therapy Surgery

Transcatheter arterial embolisation should
be considered as the next alternative after
unsuccessful endoscopy, because it is
effective and associated with less risk of
major complications than surgery
If transcatheter arterial embolisation is unsuccessful or not
available, surgery is the only remaining treatment to stop
peptic ulcer bleeding. A minimal surgical approach with
over-sewing of the ulcer is preferable, but depending on size
and location of ulcer, open surgery may be required.

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