Upper and lower GI bleeding.
Acute GI bleeding from triage to discharge: resuscitation and transfusion thresholds, endoscopy timing, Forrest stigmata, PPI, the variceal bundle, lower GI work-up, reversal agents, restarting antithrombotics and TXA.
Reviewed October 2026 · verify against current guidelines
Scoring a patient now — the GI bleed scores tool runs Glasgow-Blatchford, AIMS65, Rockall and Oakland, with the upper, variceal and lower pathways. Child-Pugh for pre-emptive TIPS is in liver scores.
Scope — adults with overt GI bleeding. Upper GI: ACG 2021, ICG 2019, ESGE 2021 and its 2026 update. Varices: Baveno VIII (2026) and AASLD 2024. Lower GI: ACG 2023. Antithrombotics: ACG-CAG 2022. Doses are the guideline regimens, not orders. Check them against your formulary and local protocol.
GI bleeding · 1 of 6
Resuscitate, then decide who needs blood.
First minutes
| Assess and treat together | Take a focused history, examine and send labs while you resuscitate, not after (ACG 2023 key concept 1). An unstable patient gets resuscitation first (ICG 2019, good practice statement A1). |
|---|---|
| Fluids before the scope | With instability or suspected ongoing bleeding, give IV fluid to restore blood pressure and heart rate before endoscopy or any intervention (ACG 2023 key concept 2). |
| Where is it coming from? | Hematemesis or melena points upper. Hematochezia with instability can still be upper: in one study of 85 high-risk hematochezia patients who had upper endoscopy first, 15% had an upper source (ACG 2023). |
| Exsanguinating | Activate the local massive transfusion protocol. Bring in GI early, with interventional radiology or surgery. |
| Known or suspected cirrhosis | Treat as variceal until proven otherwise: start a vasoactive drug and antibiotics before endoscopy (section 4). |
Transfusion thresholds (hemoglobin)
| Default: 7 g/dL | ACG 2021 (upper, conditional) and ACG 2023 (lower, hemodynamically stable, conditional). The trial behind it: restrictive 7 vs liberal 9 g/dL in 921 severe upper bleeds raised 6-week survival, 95% vs 91%, and cut further bleeding, 10% vs 16% (Villanueva 2013). |
|---|---|
| ICG 2019 differs: 8 g/dL | The International Consensus Group suggests transfusing below 80 g/L when there is no cardiovascular disease, to allow for undiagnosed heart disease (statement A4, conditional). |
| Cardiovascular disease: 8 g/dL | ACG 2021 calls 8 g/dL reasonable with pre-existing cardiovascular disease; ACG 2023 notes the same for stable lower GI bleeds. Neither has trial evidence behind it. ICG 2019 suggests a higher threshold without naming one (A5). |
| Acute coronary syndrome | ACG 2021: a threshold above 8 g/dL may be considered, on very limited evidence. ACG 2023: 8 g/dL can be considered. |
| Hypotensive or exsanguinating | Do not wait for 7 g/dL. Early hemoglobin underestimates loss until fluids equilibrate, and the trials excluded exsanguinating bleeds (ACG 2021). |
| Varices | Restrictive: about 7 g/dL unless comorbidities call for more (AASLD 2024); Baveno VIII gives an individualized 7 to 8 g/dL target (5.4). See section 4. |
Risk scores, in one paragraph
Upper: a Glasgow-Blatchford score of 0 to 1 marks very low risk. ACG 2021 suggests discharge with outpatient follow-up rather than admission (conditional); ICG 2019 and ESGE 2021 use the same cut-off. Do not use AIMS65 to pick patients for discharge (ICG 2019, A2b). Lower: an Oakland score of 8 or less identifies patients suitable for early discharge and outpatient work-up (ACG 2023, conditional). Scores supplement judgment; they never override instability or suspected varices. Run them in the GI bleed tool.
GI bleeding · 2 of 6
Upper GI: before the scope.
Pre-endoscopy
| PPI | ACG 2021 could not recommend for or against. ICG 2019 (A9): it may downstage the lesion and reduce the need for endoscopic therapy. ESGE 2026 now suggests considering high-dose IV PPI. ICG 2019 and ESGE 2026 both state that it must not delay endoscopy. |
|---|---|
| Erythromycin | ACG 2021 suggests it (conditional, very low quality): 250 mg IV, infused over 5 to 30 minutes, with endoscopy 20 to 90 minutes later. It may reduce repeat endoscopy and length of stay; it has not been shown to reduce further bleeding. Check the QT first. Metoclopramide: ACG 2021 found the evidence scant and did not support it; ESGE 2026 suggests IV metoclopramide in selected severe or ongoing bleeds when erythromycin is unavailable. |
| On anticoagulants | Do not delay endoscopy to correct anticoagulation (ICG 2019, A6). Reversal decisions are in section 6. |
Timing
| Within 24 hours | For patients admitted or under observation, low or high risk (ACG 2021, conditional; ICG 2019, B3; ESGE 2021, strong). |
|---|---|
| Faster is not better | Lau 2020 randomized 516 patients with Glasgow-Blatchford 12 or higher to endoscopy within 6 hours or at 6 to 24 hours after GI consultation. 30-day mortality: 8.9% vs 6.6%. Further bleeding: 10.9% vs 7.8%. Neither difference was significant. |
| The exception | Still unstable despite adequate resuscitation: endoscopy or interventional radiology urgently. ESGE 2026 advises against routine endoscopy within 6 or 12 hours except in this group, and Lau 2020 excluded it. |
GI bleeding · 3 of 6
Read the ulcer, then protect the clot.
Forrest stigmata and what they mean
| Ia spurting · Ib oozing | Active bleeding: high risk of persistent bleeding or rebleeding. Endoscopic therapy (ACG 2021, strong). In a meta-analysis it cut persistent or recurrent bleeding, number needed to treat 2 (ESGE 2015). |
|---|---|
| IIa visible vessel | High risk even without active bleeding. Endoscopic therapy (ACG 2021, strong); number needed to treat 5 (ESGE 2015). |
| IIb adherent clot | Irrigate to dislodge it (ICG 2019, B5). About 25% rebled within 30 days without endoscopic therapy (ESGE 2015). ACG 2021 could not recommend for or against treating it. ESGE 2026 suggests clot removal and therapy if the endoscopist can manage the lesion beneath. If left untreated, give high-dose PPI (ESGE 2021). |
| IIc flat spot · III clean base | Low risk. No endoscopic therapy (ICG 2019, B4). Selected patients can go home soon after endoscopy (ICG 2019, A8). |
After hemostasis of a high-risk ulcer
| Days 1 to 3 | High-dose PPI, continuous or intermittent (ACG 2021, strong). Continuous: 80 mg IV bolus, then 8 mg/h for 3 days. Intermittent: 80 mg bolus, then 40 mg 2 to 4 times daily, orally if feasible. |
|---|---|
| Days 4 to 14 | Twice-daily oral PPI for high-risk patients (ACG 2021 and ICG 2019, conditional). In the trial, Rockall 6 or more, further bleeding by day 28 was 10.8% on twice daily vs 28.7% on once daily. |
| After day 14 | Once daily, for as long as the cause requires (ICG 2019, C4 and C5). |
| Rebleeding | Repeat endoscopic therapy first, rather than surgery or embolization (ACG 2021, conditional); over-the-scope clips are an option for recurrent ulcer bleeding (ACG 2021 #12; ESGE 2026 #16). If endoscopy fails, transcatheter arterial embolization next (ACG 2021). Surgery if embolization fails or is unavailable (ESGE 2026). ESGE 2026 (#14) also suggests considering prophylactic embolization in selected high-risk ulcers, such as instability at presentation, a posterior duodenal wall ulcer or an ulcer larger than 2 cm. |
| H. pylori | Test every bleeding peptic ulcer, treat if positive, and confirm eradication. Repeat a negative test taken during the acute bleed (ICG 2019, D5 and D6). |
Pitfalls — giving PPI or erythromycin in place of, or before, a timely scope. Calling a clot low risk without irrigating it. Discharging without an H. pylori result or a repeat test plan. Stopping cardiac aspirin by reflex (section 6).
GI bleeding · 4 of 6
Varices: drug, antibiotic, band, consider TIPS.
The bundle (Baveno VIII 2026, AASLD 2024)
| Vasoactive drug, now | Start as soon as variceal bleeding is suspected, before endoscopy. Continue 2 to 5 days, or until TIPS (Baveno VIII 5.7; AASLD 25 and 26). Octreotide per AASLD Table 5: 50 mcg IV bolus, then 25 to 50 mcg/h. Terlipressin and somatostatin are alternatives where available. After successful endoscopic hemostasis, a course as short as 24 hours can be considered if a nonselective beta-blocker is then started (5.8). |
|---|---|
| Antibiotic, now | Recommended at presentation (Baveno VIII 5.10, strong). Third-generation cephalosporin preferred, adjusted to local resistance (5.11). AASLD 27: ceftriaxone 1 g IV every 24 hours, up to 5 days, stopped once bleeding is controlled if there is no infection. Child-Pugh A may need a shorter course or none (5.10, weak). |
| Airway | Intubate before endoscopy for altered consciousness or active hematemesis; extubate as soon as possible (5.5, 5.6). Place a nasogastric tube with caution (5.13). |
| Erythromycin | 250 mg IV, 30 to 90 minutes before endoscopy, if the QT is not prolonged (5.20, weak). AASLD: 125 to 250 mg, 30 to 120 minutes before. |
| Endoscopy within 12 hours | After resuscitation; as soon as possible if unstable (Baveno VIII 5.18; AASLD 30). Band ligation for esophageal and GOV-1 varices (5.29; AASLD 31). |
| Also | Manage in intensive or intermediate care (5.21). Lactulose, oral or by enema, to prevent or treat hepatic encephalopathy (5.22, strong). Stop a pre-endoscopy PPI once a portal hypertensive source is confirmed, unless strongly indicated (5.14). Contrast CT or MRI for portal vein thrombosis and HCC (5.30). |
| Bleeding not controlled | Intubate. Bridge with a covered esophageal stent where available, preferred over a balloon (Baveno VIII 5.35; stents are not FDA approved in the US), or balloon tamponade, limited to 24 hours (AASLD 34 and text). Call IR for salvage TIPS (Baveno VIII 5.36 and 5.37; AASLD 35). Rebleeding within 5 days despite vasoactive drug and banding: consider rescue TIPS; repeat endoscopy is an alternative (AASLD 35 and text). |
| GOV-2 or IGV-1 | A high-risk bleed that needs a multidisciplinary plan. Immediate hemostasis with cyanoacrylate injection or EUS-guided therapy, then TIPS, with or without embolization, as soon as possible as definitive treatment (Baveno VIII 5.39 to 5.41). AASLD 2024: cyanoacrylate, TIPS or retrograde obliteration (BRTO) are first-line options (45); cyanoacrylate is not FDA approved in the US for this use. Choose TIPS or BRTO by patient: BRTO may be preferred with encephalopathy or MELD-Na above 20. |
Do not over-transfuse — extra volume raises portal pressure. In Villanueva 2013, the portal-pressure gradient rose on the liberal (9 g/dL) strategy but not on the restrictive one, and survival was better with restrictive transfusion in Child-Pugh A and B cirrhosis. Target hemoglobin about 7 g/dL unless comorbidities call for more (AASLD 28); Baveno VIII gives 7 to 8 g/dL, individualized for cardiovascular disease, age, hemodynamics and ongoing bleeding (5.4). Do not give FFP or platelets to hit INR or platelet targets (Baveno VIII 5.23; AASLD 29). Platelets and fibrinogen are not routine, but may be considered if bleeding cannot be controlled (Baveno VIII 5.24).
Pre-emptive TIPS: who qualifies (Baveno VIII 5.31; AASLD 32)
- Bleeding from esophageal or GOV-1 varices, plus any one of the criteria below.
- Child-Pugh C, 10 to 13 points.
- Child-Pugh B, more than 7 points, with active bleeding at the first endoscopy.
- HVPG of 20 mmHg or more at the time of bleeding (Baveno VIII). AASLD notes that measuring HVPG during an acute bleed is challenging and not recommended.
- Timing: covered stent within 72 hours, ideally within 24. If that window was missed, TIPS within 2 weeks (Child C 10 to 13) or within 1 week (Child B with active bleeding) may still help (5.32, weak).
- ACLF, overt encephalopathy, high bilirubin, MELD or severe alcohol-related hepatitis are not absolute contraindications (5.33). No TIPS center on site: consider transfer (AASLD 32).
GI bleeding · 5 of 6
Lower GI: image the unstable, scope the stable.
ACG 2023 lower GI pathway
| Stable, low risk | An Oakland score of 8 or less supports early discharge and outpatient evaluation (recommendation 1, conditional). |
|---|---|
| Ongoing, hemodynamically significant hematochezia | CT angiography first (7, conditional). It has low yield once bleeding has stopped or is minor. A shock index of 1 or more can help predict a positive CTA, but it has not been shown to be strongly predictive of outcomes. ACG and the Society of Abdominal Radiology (2024) agree: CTA first if unstable; it could be considered first in a stable patient with suspected active bleeding; it is not a first-line test once bleeding has subsided. |
| CTA shows extravasation | Prompt referral to interventional radiology for angiography and possible embolization (8, strong). Expert centers may scope instead. |
| Could it be upper? | If the patient is unstable and suspicion is high, do an upper endoscopy to exclude a proximal source (key concept 3). |
| Colonoscopy | For most hospitalized patients (6a, strong), done nonurgently. Urgent colonoscopy within 24 hours has not improved rebleeding or mortality (9, strong, moderate quality). It can be skipped if bleeding has stopped and a high-quality colonoscopy within 12 months showed diverticulosis without neoplasia (6b). |
| At colonoscopy | Prep the bowel: 4 to 6 L of PEG is the traditional regimen, and split-dose or low-volume preps are alternatives. Unprepped colonoscopy is not recommended unless the source is anorectal or distal (key concept 8). Treat diverticular stigmata with through-the-scope clips, band ligation or coagulation (10, strong). |
| Platelets | In severe bleeding, keep the platelet count above 30 x 109/L, or above 50 if a procedure is planned. Do not transfuse platelets routinely for antiplatelet drugs (key concept 5). |
Next decision — stable patient with a self-limited bleed: admit for a nonurgent colonoscopy, or discharge for outpatient evaluation if the Oakland score is 8 or less. Ongoing bleeding with instability: CTA now, then IR. Unstable with a negative CTA: think upper source.
GI bleeding · 6 of 6
Antithrombotics: reverse rarely, restart deliberately. Skip TXA.
Reversal: when, and with what
| Warfarin | Most patients do not need reversal. ACG-CAG 2022 suggests against FFP and against vitamin K. If reversal is needed, choose PCC over FFP. Consider PCC for life-threatening bleeding, an INR well above range, or when massive transfusion is undesirable. ACG 2023 (lower GI): reverse only a life-threatening bleed with an INR substantially above range (3, conditional), choosing PCC over FFP (ACG-CAG rec 3). |
|---|---|
| Dabigatran | Routine idarucizumab is suggested against (ACG-CAG 2022). Consider it for a life-threatening bleed if the dose was taken within the past 24 hours. |
| Factor Xa inhibitors | Routine reversal is suggested against: no routine PCC or andexanet alfa (ACG-CAG 2022). Andexanet has not been sold in the US since December 22, 2025; the FDA considers its risks to outweigh its benefits. For a life-threatening bleed with a dose in the past 24 hours, ACG-CAG allows selective PCC, but the evidence is weak: ACG 2023 found no definitive role for PCC in factor Xa reversal. Follow the local reversal protocol with hematology. ACG 2023 limits any reversal to bleeds that do not respond to resuscitation and stopping the drug (4, conditional). |
| Antiplatelets | Platelet transfusion to reverse antiplatelet drugs is suggested against (ACG-CAG 2022). |
| Endoscopy | Do not delay it for anticoagulation (ICG 2019). Lower GI: endoscopic hemostasis can be considered safe at an INR of 2.5 or less (ACG 2023 key concept 4). |
Holding and restarting
| Aspirin, secondary prevention | Do not hold it (ACG-CAG 2022, conditional). If it was stopped, restart on the day endoscopic hemostasis is confirmed (ACG-CAG 2022); ESGE 2021 says preferably within 3 to 5 days. In lower GI bleeding, continue it if possible and consider a brief pause only for severe or ongoing bleeding (ACG 2023 key concept 6). |
|---|---|
| Aspirin, primary prevention | Hold it and review the indication. After diverticular hemorrhage, ACG 2023 suggests stopping it (11b). |
| P2Y12 inhibitor or DAPT | Lower GI (ACG 2023): keep aspirin and hold the P2Y12 inhibitor initially in severe bleeding. A stent within the last year needs a multidisciplinary decision, and the P2Y12 inhibitor should restart within 5 days at most. ACG-CAG 2022 makes no acute-bleeding recommendation on P2Y12 inhibitors, so decide with cardiology. |
| Anticoagulant | Restart once bleeding has stopped; restarting lowers thromboembolism and mortality (ACG 2023, 12, strong). Usually within 7 days (ACG 2023; ESGE 2021). ESGE 2026: as soon as clinically indicated by thrombotic risk. DOACs act faster than warfarin, so factor that in (ESGE 2021). After a variceal bleed, timing is individualized (Baveno VIII 5.26). |
| Long-term protection | After an ulcer bleed, give a PPI to patients who must stay on antiplatelet or anticoagulant therapy (ICG 2019, E4 and E5). |
Tranexamic acid: don't — HALT-IT randomized 12,009 patients with significant upper or lower GI bleeding. Death from bleeding within 5 days was 4% on TXA and 4% on placebo (RR 0.99). Venous thromboembolism was 0.8% vs 0.4% (RR 1.85). ACG 2023 recommends against it in lower GI bleeding (strong), and Baveno VIII advises against it in variceal bleeding (5.25). The broader TXA evidence is in TXA part 1 and part 2.
Newer guidance, October 2026 — ASGE published guidelines on variceal bleeding (September 2026, doi:10.1016/j.gie.2026.07.026) and on endoscopy in lower GI bleeding (August 2026, doi:10.1016/j.gie.2026.06.046) after this page's sources were reviewed. Their recommendations are not reflected here.
ACLF acute-on-chronic liver failureBRTO balloon-occluded retrograde transvenous obliterationCTA computed tomography angiographyDAPT dual antiplatelet therapyDOAC direct oral anticoagulantEUS endoscopic ultrasoundFFP fresh frozen plasmaGOV-1 type 1 gastroesophageal varicesGOV-2 type 2 gastroesophageal varicesHVPG hepatic venous pressure gradientIGV-1 type 1 isolated gastric varicesIR interventional radiologyPCC prothrombin complex concentratePEG polyethylene glycolPPI proton pump inhibitorTIPS transjugular intrahepatic portosystemic shuntTXA tranexamic acid
Educational reference only — not medical advice. Verify against local protocol.
Sources
Verify against current guidelines and local protocol before acting.
- Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol 2021;116(5):899-917. doi:10.14309/ajg.0000000000001245. Statements 1-16 and text. Current ACG UGIB guideline as of October 2026.
- Sengupta N, Feuerstein JD, Jairath V, et al. Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline. Am J Gastroenterol 2023;118(2):208-231. doi:10.14309/ajg.0000000000002130. Table 1 recommendations 1-12; Table 2 key concepts.
- Abraham NS, Barkun AN, Sauer BG, et al. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. Am J Gastroenterol 2022;117(4):542-558. doi:10.14309/ajg.0000000000001627. Recommendations 1-10.
- Barkun AN, Almadi M, Kuipers EJ, et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med 2019;171(11):805-822. doi:10.7326/M19-1795. Table 1, statements A1-E5 (statements marked unchanged from 2003 and 2010 included).
- Gralnek IM, Stanley AJ, Morris AJ, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): ESGE Guideline - Update 2021. Endoscopy 2021;53(3):300-332. doi:10.1055/a-1369-5274. Recommendations 1-10 (abstract).
- Gralnek IM, Morris J, Laursen SB, Camus M, et al. Endoscopic diagnosis and management of peptic ulcer bleeding: ESGE Guideline - Update 2026. Endoscopy 2026. doi:10.1055/a-2863-8314 (correction doi:10.1055/a-2881-7411). New and revised recommendations 1-19 (abstract).
- Gralnek IM, Dumonceau JM, Kuipers EJ, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: ESGE Guideline. Endoscopy 2015;47(10):a1-46. doi:10.1055/s-0034-1393172. Forrest classification text (natural history of adherent clot; endoscopic therapy meta-analysis). Author manuscript: hdl.handle.net/2318/1526175.
- Kaplan DE, Ripoll C, Thiele M, et al. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024;79(5):1180-1211. doi:10.1097/HEP.0000000000000647. Guidance statements 25-35 and 45, Table 5, and gastric varix text.
- Baveno VIII Faculty (Berzigotti A, Mandorfer M, et al.). Baveno VIII - Advancing consensus in portal hypertension. J Hepatol 2026 (journal pre-proof, online August 2026). doi:10.1016/j.jhep.2026.07.030. Panel 5, statements 5.1-5.41. Conference held March 2026.
- Lau JYW, Yu Y, Tang RSY, et al. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. N Engl J Med 2020;382(14):1299-1308. doi:10.1056/NEJMoa1912484.
- Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013;368(1):11-21. doi:10.1056/NEJMoa1211801.
- HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet 2020;395(10241):1927-1936. doi:10.1016/S0140-6736(20)30848-5.
- Sengupta N, Kastenberg DM, Bruining DH, et al. The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology. Am J Gastroenterol 2024;119(3):438-449 (also Radiology 2024;310(3):e232298). doi:10.14309/ajg.0000000000002631.
- US Food and Drug Administration. Update on the safety of Andexxa (AstraZeneca): FDA safety communication, December 2025. Sales ended December 22, 2025. fda.gov/safety/medical-product-safety-information/update-safety-andexxa-astrazeneca-fda-safety-communication
- Not yet reviewed (texts not accessible): ASGE guideline on management of esophageal and gastric varices in patients with cirrhosis. Gastrointest Endosc 2026. doi:10.1016/j.gie.2026.07.026. ASGE guideline on the role of endoscopy in acute lower gastrointestinal bleeding. Gastrointest Endosc 2026. doi:10.1016/j.gie.2026.06.046.
- Facts restated in our own words; no society figure, table or algorithm is reproduced.