guidelines

acute upper gi bleeding

nice cg141 summary: risk scoring (blatchford/rockall), resuscitation, endoscopy timing, ppi use, variceal bleed bundle (terlipressin + antibiotics), and antithrombotic reversal considerations.

last reviewed: 2026-02-14
based on: NICE CG141 (published Jun 2012; last updated Oct 2017) + linked MHRA DOAC reversal advice + TA references where applicable
reviewer: Dr Kola Tytler MBBS CertHE MBA MRCGP
view official NICE source

Executive summary

  • Risk score early: use Blatchford at first assessment; use full Rockall after endoscopy.
  • Early discharge: consider only if pre-endoscopy Blatchford = 0 and clinically stable.
  • Endoscopy timing: unstable severe bleeding → immediately after resuscitation; otherwise within 24 hours of admission.
  • PPI rule: do not give PPIs before endoscopy for suspected non-variceal bleed; do give PPI after endoscopy if stigmata of recent haemorrhage.
  • Suspected variceal bleed: give terlipressin at presentation and prophylactic antibiotics; definitive haemostasis typically via band ligation (oesophageal varices).

Resuscitation & antithrombotics (the “must know” bits)

  • Manage massive haemorrhage with blood/products per local protocol; avoid over- and under-transfusion by using the full clinical picture.
  • Platelets: do not transfuse if not actively bleeding and stable; offer platelets if actively bleeding and platelets <50 × 10^9/L.
  • Warfarin + active bleed: offer prothrombin complex concentrate.
  • DOAC reversal: NICE directs clinicians to MHRA advice on reversal agents; do not improvise—use local major haemorrhage pathways.

Endoscopy & definitive management (CG141 core recommendations)

  • Timing:
    • Unstable severe bleed → endoscopy immediately after resuscitation
    • All others → endoscopy within 24 hours
  • Non-variceal endoscopic therapy: avoid adrenaline monotherapy; use clips ± adrenaline, thermal + adrenaline, or fibrin/thrombin + adrenaline.
  • Variceal bundle:
    • Terlipressin at presentation; stop after definitive haemostasis or after 5 days (unless another indication).
    • Prophylactic antibiotics at presentation.
    • Oesophageal varices → band ligation; consider TIPS if uncontrolled.
  • PPIs: do not give pre-endoscopy for suspected non-variceal bleed; do give post-endoscopy if stigmata of recent haemorrhage.

References (Harvard):

  • NICE (2017) Acute upper gastrointestinal bleeding in over 16s: management (CG141). https://www.nice.org.uk/guidance/cg141

FAQs

Should I start a PPI immediately in suspected non-variceal UGIB?
NICE advises not to offer acid-suppression (PPI/H2RA) before endoscopy for suspected non-variceal UGIB. Start PPI after endoscopy if stigmata of recent haemorrhage are seen.
When can low-risk patients go home?
CG141 says consider early discharge if pre-endoscopy Blatchford score is 0 and the patient is otherwise clinically stable.
What’s the “variceal bundle”?
At presentation: terlipressin + prophylactic antibiotics, alongside urgent endoscopic haemostasis pathways.

Transparency

This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.