Acute Upper GI Bleeding: The Definitive Guide to Stabilization, Restrictive Transfusion, and Timely Endoscopy (ACG Guidelines)

In this episode of Hospital Medicine Unplugged, we unpack the evidence-based inpatient management of upper gastrointestinal bleeding (UGIB)—from triage at the door to secondary prevention at discharge.

We open with stabilization: airway protection when mental status or torrential hematemesis threatens, two large-bore IVs, targeted labs (CBC, CMP, coagulation studies, type & cross), and a restrictive transfusion strategy (Hb <7 g/dL for most; <8 g/dL if CAD or ongoing massive bleed). We cover when to reverse coagulopathy and why platelets <50k with active bleeding warrant transfusion.

Next, risk tools that actually change what you do: Glasgow-Blatchford Score to decide ED discharge vs admission and to prioritize endoscopy; how AIMS65 and Rockall complement mortality prognostication.

Then the meds—started early:

• High-dose IV PPI (bolus + infusion, or guideline-supported intermittent high-dose) for suspected peptic ulcer bleeding.

• Erythromycin 250 mg IV pre-scope to clear the stomach.

• For suspected varices: vasoactive therapy (e.g., octreotide) and ceftriaxone prophylaxis right away.

• Why tranexamic acid is out in UGIB.

Endoscopy timing and technique: perform within 24 hours in most, sooner (≈12 h) if unstable after resuscitation. For non-variceal bleeds, we highlight combination therapy (epinephrine plus thermal or clips) over epinephrine alone; when to reach for over-the-scope clips or hemostatic powder. For varices: band ligation for esophageal, cyanoacrylate for gastric.

Post-endoscopic care that prevents rebleeding: 72 hours of high-dose PPI, early enteral nutrition, and criteria for repeat endoscopy if rebleeding occurs. For variceal hemorrhage: continue vasoactives and antibiotics, start NSBBs, and plan serial EVL.

Rescue playbook: when to call IR for arterial embolization in refractory non-variceal bleeding; balloon tamponade as a bridge in uncontrolled variceal hemorrhage; early or salvage TIPS in high-risk cirrhotics who keep bleeding despite optimal therapy.

We round out with special situations—cirrhosis (infection risk, renal vulnerability), patients on anticoagulants/antiplatelets (who to reverse, and how/when to resume), and the elderly with multimorbidity. Plus the system moves: GI-bleed pathways, early GI/hepatology involvement, ICU vs ward triage, and why standardized order sets improve outcomes.

Concise, guideline-driven, practical medicine—no fluff, just the evidence for safer, more effective inpatient management of UGIB.