First hour
- Two large-bore IVs, crystalloid if hemodynamically unstable (ESGE 2021). Monitored bed if unstable.
- Bloods: CBC, group and screen/crossmatch, INR, urea, creatinine, liver tests, lactate.
- Ask about: anticoagulants, antiplatelets, NSAIDs, liver disease, alcohol, prior bleeding.
- Airway: intubate before endoscopy only if ongoing hematemesis, agitation, or encephalopathy with an unprotected airway (ESGE 2021 Rec 17; Baveno VII 6.3). Not routinely.
- No routine NG tube (ESGE 2021).
- No tranexamic acid (ESGE 2021, strong recommendation).
Transfusion
| Patient | Transfuse when Hb | Target |
|---|---|---|
| Stable, no cardiovascular disease (ACG 2021; ESGE 2021) | ≤70 g/L | 70–90 g/L |
| Stable, no cardiovascular disease (International Consensus 2019) | <80 g/L | >80 g/L |
| Cardiovascular disease (ESGE 2021) | ≤80 g/L | ≥100 g/L |
| Variceal bleed (Baveno VII) | Conservative | 70–80 g/L |
Guidelines differ for patients without cardiovascular disease (70 vs 80 g/L). Both are restrictive. This card follows the newer ACG and ESGE threshold of 70 g/L, and 80 g/L with cardiovascular disease.
Thresholds do not apply to exsanguinating bleeding: transfuse to the clinical picture, not the first Hb (International Consensus 2019).
Risk score
Glasgow-Blatchford score ≤1: very low risk; can be managed as an outpatient with outpatient endoscopy (ACG 2021; ESGE 2021; International Consensus 2019). Anyone else is admitted.
Before endoscopy
- PPI: high-dose IV PPI may be considered (e.g. pantoprazole or esomeprazole 80 mg IV); it can downstage stigmata but must not delay endoscopy (ESGE 2021 and 2026). In variceal bleeding, stop the PPI after endoscopy unless there is a clear indication (Baveno VII 6.12).
- Erythromycin 250 mg IV, 30–120 minutes before endoscopy, in severe or ongoing bleeding (ESGE 2021; ACG 2021; Baveno VII). Avoid with a prolonged QT or macrolide allergy. If IV erythromycin is unavailable, IV metoclopramide is an alternative in selected patients (ESGE 2026).
- Anticoagulants: do not delay endoscopy (International Consensus 2019). See the antithrombotic table below.
Scope: when
| Bleed | Timing |
|---|---|
| Non-variceal | Within 24 h of presentation, after resuscitation (ACG 2021; ESGE 2021; International Consensus 2019) |
| Non-variceal, unstable despite resuscitation | Sooner. ESGE 2026 advises against routine ≤6 h or ≤12 h endoscopy otherwise |
| Suspected variceal | Within 12 h of presentation; as soon as safely possible if unstable (Baveno VII; ESGE 2022) |
After endoscopic therapy (ulcer with high-risk stigmata)
- Pantoprazole or esomeprazole 80 mg IV bolus, then 8 mg/h for 72 h (International Consensus 2019; ESGE 2021). Intermittent high-dose IV bolus twice daily is an acceptable alternative (ESGE 2021; ACG 2021).
- Then oral PPI twice daily to day 14, then once daily for a duration that depends on the lesion (International Consensus 2019; ACG 2021).
- Rebleeding: repeat endoscopy, considering an over-the-scope clip; if that fails, transcatheter embolisation, then surgery (ACG 2021; ESGE 2026).
- Very high-risk ulcer (unstable at presentation, posterior duodenal wall, >2 cm, or doubtful hemostasis): ESGE 2026 suggests considering prophylactic embolisation; discuss with IR.
- Feed within 24 h once hemostasis is durable; start iron before discharge if iron deficient or anemic (ESGE 2026).
Non-ulcer, non-variceal lesions (CAG 2025)
| Lesion | Suggested endoscopic therapy |
|---|---|
| Mallory-Weiss tear, actively bleeding | Band ligation or through-the-scope clip, not epinephrine alone |
| Mallory-Weiss tear, not bleeding (even with a visible vessel or clot) | No endoscopic therapy |
| Dieulafoy lesion | Band ligation or clip, contact thermal therapy or sclerosant, not epinephrine alone |
| Gastric antral vascular ectasia (GAVE) | Band ligation over argon plasma coagulation |
| Actively bleeding tumour | Topical hemostatic agent (e.g. hemostatic powder) over conventional therapy; then oncologic therapy after the endoscopic treatment |
All are conditional recommendations from the first guideline on these lesions (CAG 2025, endorsed by ASGE, ESGE and AGA).
Suspected variceal bleed: the bundle
- Octreotide 50 µg IV bolus, then 50 µg/h infusion; a second 50 µg bolus may be given at 1 h if bleeding continues (Calmet 2022). Continue 2–5 days (Baveno VII 6.5).
- Ceftriaxone 1 g IV every 24 h, from admission, for up to 7 days (Baveno VII 6.7–6.9; ESGE 2022). Adjust to local resistance and allergy.
- Lactulose (oral or enema) to clear blood and prevent encephalopathy (Baveno VII 6.33).
- Do not give FFP to correct INR; INR does not reflect hemostasis in cirrhosis (Baveno VII 6.34–6.36).
- Endoscopy: band ligation for esophageal varices; tissue adhesive (cyanoacrylate) for GOV2 and IGV1; ligation or adhesive for GOV1 (Baveno VII 6.21–6.23).
- Cross-sectional imaging (CT or MRI) to look for portal vein thrombosis and HCC (Baveno VII 6.26).
Pre-emptive TIPS (within 72 h, ideally <24 h)
For bleeding esophageal or GOV1/GOV2 varices with any of (Baveno VII 6.27):
- Child-Pugh C, <14 points (i.e. 10–13)
- Child-Pugh B >7 with active bleeding at the initial endoscopy
- HVPG >20 mmHg at the time of bleeding
Hepatic encephalopathy, ACLF or high bilirubin on admission are not contraindications (6.28). TIPS may be futile at Child-Pugh ≥14 unless transplant is planned (6.31). Call hepatology and IR early.
Refractory variceal bleeding
Balloon tamponade or a self-expanding esophageal stent as a bridge to rescue TIPS (Baveno VII 6.29–6.30).
Anticoagulants and antiplatelets
| Drug | During the bleed | Restart |
|---|---|---|
| Warfarin | Hold. No routine FFP or vitamin K (ACG–CAG 2022). If reversal is needed (life-threatening bleed, INR far above range), PCC over FFP | As soon as bleeding is controlled, preferably within or soon after 7 days, by thrombotic risk (ESGE 2021) |
| DOAC | Hold. ACG–CAG 2022 suggests against PCC, idarucizumab and andexanet. ESGE 2021: consider a reversal agent or PCC in severe ongoing bleeding. Andexanet (Ondexxya) is no longer marketed in Canada (cancelled August 2026); idarucizumab (dabigatran) still is | As above; DOACs act within hours |
| ASA, secondary prevention | Do not stop | If stopped, restart the day hemostasis is confirmed (ACG–CAG 2022) |
| ASA, primary prevention | Stop | Re-evaluate the indication (ESGE 2021) |
| Dual antiplatelet therapy | Continue ASA; interrupt the P2Y12 inhibitor; involve cardiology | P2Y12 inhibitor within 5 days (ESGE 2021) |
| Any antiplatelet | No platelet transfusion (ACG–CAG 2022; ESGE 2021) |
Mechanical valve, recent VTE or recent coronary stent: involve thrombosis or cardiology before holding or reversing.
Red flags
- Shock, ongoing hematemesis, or a falling Hb despite transfusion.
- Cirrhosis with encephalopathy or Child-Pugh C.
- Rebleeding after endoscopic therapy.
Pitfalls
- Delaying endoscopy for INR correction.
- Over-transfusing a variceal bleed.
- Forgetting ceftriaxone in cirrhosis.
- Stopping cardiac ASA “to be safe.”
Follow your local protocols for dosing, renal adjustment and allergy.