01Approach to the Critical Patient/attcp53

Immediate resuscitation priorities

›Airway and aspiration risk

›Large-volume hematemesis with altered consciousness

›Intubation before endoscopy if airway not protectable

›RSI preparation with cricoid pressure consideration

›Active vomiting of blood impairing airway

›Suction at bedside

›Lateral decubitus positioning

›SpO2 target >= 94% on supplemental oxygen

›HFNC if respiratory distress without active vomiting

›Circulatory resuscitation

›Two large-bore IVs (16G or larger) or central access

›Antecubital or external jugular as first choice

›IO access if IV access fails in unstable patient

›Crystalloid bolus 500 mL for hemodynamic instability

›Reassess after each bolus; avoid volume overload

›Target MAP >= 65 mmHg

›Massive transfusion protocol activation triggers

›SBP < 90 mmHg unresponsive to initial crystalloid

›HR > 120 with ongoing hematemesis

›pRBC:FFP:platelets in 1:1:1 ratio if activated

›Restrictive transfusion strategy

›Transfuse pRBCs when Hgb < 7.0 g/dL (70 g/L) in most patients

›Class I recommendation (ACG 2021)

›Target Hgb 7–9 g/dL post-transfusion

›Higher transfusion threshold Hgb < 8.0 g/dL (80 g/L) in

›Acute coronary syndrome or severe cardiovascular disease

›Hemodynamically unstable patients

02History/hx60

Bleeding presentation

›Character of blood loss

›Hematemesis (bright red blood)

›Implies brisk active bleeding from proximal source

›Coffee-ground emesis

›Partially digested blood; slower bleed rate

›Melena (black tarry stools)

›>= 50 mL blood loss proximal to right colon

›Hematochezia with hemodynamic instability

›Suggests massive UGIB with rapid transit

›Temporal features

›Onset (acute vs. chronic/relapsing)

›Number of emesis episodes and estimated volume

›Duration of melena prior to presentation

›Prior identical episodes or known PUD history

PUD symptom history

›Classic ulcer symptoms

›Epigastric pain present in approximately 81% of PUD patients

›Burning or gnawing quality

›Duodenal ulcer: pain relieved with food

›Gastric ulcer: pain worsened postprandially

›Nocturnal awakening with pain (41% of PUD patients)

›Nausea and vomiting (25%)

›Belching and bloating (43%)

›Nearly half of patients with bleeding PUD have no preceding warning symptoms

Alarm features and red flags

›Hemodynamic symptoms

›Syncope or pre-syncope

03Physical Exam/exam52

Hemodynamic assessment

›Vital sign pattern

›Heart rate: tachycardia > 100 bpm as marker of significant blood loss

›GBS adds +1 point for HR >= 100

›Blood pressure

›SBP < 100 mmHg indicates hemodynamic compromise

›Orthostatic drop: SBP fall >= 20 mmHg or HR rise >= 20 bpm

›Respiratory rate elevation as compensation marker

›Oxygen saturation as airway safety surrogate

›Volume status assessment

›Capillary refill time > 2 seconds

›Skin turgor and mucous membrane moisture

›Peripheral extremity temperature (cold peripheries)

›Jugular venous pressure estimation

Abdominal exam

›Epigastric findings

›Epigastric tenderness on palpation

›Severity: mild to moderate in uncomplicated PUD

›Severe rigidity suggests perforation

›Peritoneal signs

›Guarding and rebound tenderness

›Board-like abdomen: emergent surgical evaluation

›Hepatomegaly or splenomegaly

›Suggests portal hypertension and variceal etiology

›Ascites

›Fluid wave or shifting dullness

›Cirrhosis and portal hypertension marker

›Bowel sounds

04Differential Diagnosis/ddx40

Life-threatening diagnoses

›Esophagogastric varices

›ICD-10 I85.01 (esophageal varices with bleeding)

›Cirrhosis or portal hypertension history

›Large volume hematemesis

›Stigmata of chronic liver disease on exam

›Aortoenteric fistula

›ICD-10 K63.2

›Prior aortic graft (sentinel/herald bleed followed by massive hemorrhage)

›Cannot-miss diagnosis in any patient with aortic graft and UGIB

›Perforated peptic ulcer with bleeding

›ICD-10 K27.2 (with hemorrhage and perforation)

›Sudden severe abdominal pain with peritoneal signs

›Free air on imaging

Common causes of UGIB

›Peptic ulcer disease

›ICD-10 K27.4 (chronic peptic ulcer with hemorrhage)

›40–60% of all UGIB cases

›Epigastric pain, NSAID/H. pylori history

›Mallory-Weiss tear

›ICD-10 K22.6

›Preceded by forceful retching or vomiting

›Linear mucosal tear at gastroesophageal junction

›Often self-limited

›Erosive esophagitis or gastritis

›ICD-10 K25.4 (chronic gastric ulcer with hemorrhage)

›GERD symptoms, NSAID use

›Typically less severe bleeding

05Laboratory Tests/lt44

Initial hematologic labs

›Complete blood count

›Hemoglobin and hematocrit for transfusion threshold guidance

›Initial Hgb may not reflect acute blood loss (dilutional lag)

›Serial Hgb every 4–6 hours to trend

›Platelet count

›Target > 50 x 10^9/L before endoscopic intervention

›Thrombocytopenia suggests cirrhosis or bone marrow suppression

›MCV for chronicity assessment

›Microcytic anemia suggests chronic blood loss

Coagulation and crossmatch

›Type and screen or crossmatch

›Crossmatch 2–4 units pRBC for active bleeding

›Screen sufficient if stable and low risk

›Coagulation studies

›PT/INR

›INR > 1.5 indicates coagulopathy or anticoagulant effect

›Target INR < 2.5 before endoscopy (1.5 preferred)

›aPTT for anticoagulant monitoring

›Fibrinogen if disseminated intravascular coagulation suspected

›Thromboelastography (TEG) or ROTEM

›Guides targeted blood product resuscitation

›Available at centers performing massive transfusion

Metabolic and organ function labs

›Comprehensive metabolic panel

›BUN: creatinine ratio >= 25 strongly suggests UGIB source

›BUN elevated by blood protein digestion in small bowel

›BUN is a GBS scoring element

06Diagnostic Tests/dt79

Scoring Systems

›Glasgow-Blatchford Score (GBS)

›Purpose: predict need for intervention (transfusion, endoscopy, surgery)

›Components

›BUN (mmol/L): 0–6 points by level

›Hemoglobin (g/dL): 0–6 points by sex and level

›Systolic BP: 0–3 points (SBP < 90 mmHg = 3 points)

›HR >= 100: +1 point

›Melena: +1 point

›Syncope: +2 points

›Hepatic disease: +2 points

›Cardiac failure: +2 points

›Interpretation

›GBS 0: very low risk; outpatient management safe

›GBS 1: low risk; consider outpatient endoscopy

›GBS >= 7: high risk; intervention likely required

›GBS outperforms Rockall and AIMS65 for predicting need for intervention (BMJ 2017)

›Forrest Classification (endoscopic stigmata of hemorrhage)

›Ia: spurting arterial bleeding (highest rebleeding risk ~55%)

›Ib: oozing bleeding (~55% rebleeding without therapy)

›IIa: non-bleeding visible vessel (rebleeding risk ~43%)

›IIb: adherent clot (rebleeding ~22%)

›IIc: flat pigmented spot (rebleeding ~10%)

›III: clean base ulcer (rebleeding ~5%)

›Endoscopic therapy indicated for Forrest Ia, Ib, IIa lesions

›AIMS65 Score

›Albumin < 3.0 g/dL, INR > 1.5, altered mental status, SBP <= 90 mmHg, age >= 65 years

›Predicts in-hospital mortality better than GBS

›Score 0–1: low mortality risk; score >= 2: elevated risk

MRI

›MRI role in UGIB

›Not a first-line diagnostic tool for acute UGIB

›Time-intensive and impractical in hemodynamically unstable patients

›Potential role in subacute or obscure GI bleeding evaluation

›MR enterography for small bowel sources

›Sensitivity for active bleeding approximately 78% in small studies

›MRI angiography

›Identifies vascular malformations and Dieulafoy lesions

›Used when endoscopy and CT angiography non-diagnostic

›No ACR primary recommendation for MRI in acute nonvariceal UGIB

›ACR Appropriateness Criteria 2024

CT

›CT angiography (CTA) for UGIB

›Indications

›Hemodynamically unstable with ongoing hemorrhage prior to IR

›Failed endoscopic hemostasis or recurrent bleeding

›Obscure UGIB where endoscopy non-diagnostic

›Technical requirements

›Triphasic protocol: non-contrast, arterial, and portal venous phases

›Active bleeding detection threshold: >= 0.5 mL/min bleed rate

›Performance characteristics

›Sensitivity for active extravasation: 79–100%

›Specificity: approximately 95–100%

›Can localize bleeding source to guide TAE

›ACR Appropriateness Criteria 2024

›CTA abdomen/pelvis usually appropriate for acute nonvariceal UGIB with recurrent or hemodynamically significant bleeding

›CT without contrast

›Limited utility for active bleeding

›Useful for detecting perforation (free air) or obstruction

›CT findings in PUD complications

›Pneumoperitoneum: free subdiaphragmatic air (perforation)

›Pneumatosis intestinalis: ischemic complication

›Wall thickening at ulcer site

Ultrasound

›Point-of-care ultrasound (POCUS) in UGIB

›Hepatic and portal assessment

›Liver nodularity and echogenicity (cirrhosis)

›Portal vein diameter > 13 mm suggests portal hypertension

›Splenomegaly (> 12 cm)

›Ascites detection

›IVC collapsibility index

›> 50% collapse suggests volume depletion

›Guides fluid resuscitation aggressiveness

›Cardiac function assessment

›LV systolic function for resuscitation targeting

›Pericardial effusion exclusion

›Doppler ultrasound

›Hepatic vein and portal vein flow assessment

›Identifies portal vein thrombosis complicating cirrhosis

›Not used for primary diagnosis of active UGIB

›Limitations

›Cannot directly visualize intraluminal bleeding source

›Bowel gas limits visualization of gastric and duodenal mucosa

07Disposition/dispo32

Discharge criteria (low-risk)

›Safe discharge from ED

›GBS 0: very low risk; discharge with outpatient endoscopy appropriate

›Class I recommendation (ACG 2021)

›GBS 1: may be considered for safe discharge in select cases

›Outpatient endoscopy must be arranged within 24–72 hours

›Additional discharge criteria

›Hemodynamically stable without orthostatic changes

›No active hematemesis or ongoing melena

›Hgb stable and above transfusion threshold

›Reliable follow-up and able to recognize return precautions

›No significant comorbidities altering threshold

Admission indications

›Floor/ward level admission

›GBS 2–6 with hemodynamic stability

›No active comorbidities requiring intensive monitoring

›Single-session endoscopy anticipated within 24 hours

›ICU or monitored bed admission

›Hemodynamic instability at any point

›Active hematemesis or rapid ongoing blood loss

›GBS >= 7 or Forrest Ia/Ib on endoscopy

›Significant comorbidities: cardiac, hepatic, renal

›Need for urgent endoscopy within 6–12 hours

›Coagulopathy requiring active correction

›Massive transfusion requirement

Transfer criteria

›Transfer to tertiary center triggers

›Endoscopic hemostasis failure requiring TAE or surgery

08Treatment/t103

Pre-endoscopy pharmacotherapy

›Proton pump inhibitor (PPI) therapy

›Initiate IV PPI immediately upon diagnosis of UGIB

›Pantoprazole 80 mg IV bolus then 8 mg/hr continuous infusion

›Alternative: esomeprazole 80 mg IV bolus then 8 mg/hr infusion

›Alternative: intermittent dosing 40 mg IV q8–12h acceptable per ACG 2021

›Pre-endoscopy PPI reduces high-risk stigmata at endoscopy

›Does not reduce mortality or rebleeding rates

›Cochrane 2022: reduces need for endoscopic therapy

›H2-receptor antagonists inferior to PPIs

›Should not be substituted for PPI therapy

›Prokinetic pre-endoscopy

›Erythromycin 250 mg IV 30–90 minutes before endoscopy

›Indication: clinically severe or ongoing active bleeding

›Mechanism: motilin receptor agonist accelerates gastric emptying

›Improves gastric visualization; reduces need for second endoscopy

›Metoclopramide 10 mg IV if erythromycin unavailable

›Less evidence but acceptable alternative

›Tranexamic acid

›NOT recommended in UGIB

›HALT-IT RCT 2020: no mortality benefit; increased thromboembolic events

›ACG 2021 and ESGE 2026 both recommend against use

Endoscopic treatment

›Timing of endoscopy

›Most patients: within 24 hours of presentation

›ACG 2021 strong recommendation

›Urgent endoscopy < 6–12 hours NOT recommended before adequate resuscitation

›NEJM RCT (Lau 2020): no benefit of urgent vs. early endoscopy

›Adequate resuscitation must precede endoscopy

›Very early endoscopy (< 6 hours) only when

›Massive ongoing hemorrhage despite resuscitation

›Hemodynamic stability cannot be achieved

›Endoscopic hemostasis techniques

›Combination therapy preferred for Forrest Ia, Ib, IIa lesions

›Epinephrine injection 1:10,000 solution (injection alone insufficient)

›Combined with thermal coagulation (heater probe, bipolar) or hemoclips

›Epinephrine monotherapy is insufficient; Class I recommendation against

›Over-the-scope clips (OTSC)

›May be used as monotherapy for high-risk stigmata (ESGE 2026)

›Alternative to combination therapy for accessible lesions

›Forrest IIb (adherent clot)

›Consider clot removal followed by treatment of underlying vessel

›Acceptable to treat conservatively without clot removal in some guidelines

›Forrest IIc and III

›No endoscopic therapy required; PPI alone sufficient

Post-endoscopy PPI regimen

›High-risk stigmata (Forrest Ia, Ib, IIa) post-endoscopic treatment

›Pantoprazole or esomeprazole 80 mg IV bolus then 8 mg/hr infusion

›Duration: 72 hours post-endoscopy

›Then twice-daily oral PPI for 2 weeks

›Then once-daily oral PPI maintenance

›Duration based on etiology

›H. pylori-negative ulcers: 4–8 weeks total PPI therapy

›H. pylori-positive: continue PPI through eradication therapy completion

›Low-risk stigmata (Forrest IIc, III)

›Oral PPI once daily sufficient

›No high-dose IV PPI required

H. pylori eradication therapy

›Test all patients with bleeding PUD for H. pylori

›ACG 2021 guideline recommendation

›First-line eradication (14-day courses preferred)

›Bismuth quadruple therapy

›Bismuth subsalicylate 525 mg QID

›Metronidazole 500 mg QID

›Tetracycline 500 mg QID

›PPI standard dose BID

›Concomitant quadruple therapy (alternative)

›PPI standard dose BID

›Amoxicillin 1000 mg BID

›Clarithromycin 500 mg BID

›Metronidazole 500 mg BID

›Eradication confirmation

›Urea breath test or stool antigen >= 4 weeks after antibiotic completion

›Minimum 2 weeks off PPI before testing to avoid false negatives

›Rebleeding rate 1.3% with confirmed eradication vs. 26% without treatment (NEJM 2016)

Rebleeding management

›Clinical rebleeding triggers

›Recurrent hematemesis or melena after initial hemostasis

›HR rise > 20 bpm or SBP drop > 20 mmHg

›Hgb drop >= 2 g/dL (20 g/L) after stabilization

›Repeat endoscopy with OTSC as first intervention

›ESGE 2026 recommendation for recurrent bleeding

›Transcatheter arterial embolization (TAE)

›Indicated if second endoscopy fails or repeat endoscopy not feasible

›Gastroduodenal artery most commonly embolized for duodenal ulcers

›Technical success rate approximately 85–90%

›Surgery

›Reserve for TAE failure or unavailability

›Oversewing of bleeding vessel +/- vagotomy and pyloroplasty

Antithrombotic management

›Aspirin for secondary cardiovascular prevention

›Resume within 1–3 days after hemostasis

›RCT data: 30-day mortality 1% with early aspirin resumption vs. 9% without (NEJM 2016)

›ACG-CAG 2022 guideline recommendation

›Co-prescribe PPI when resuming aspirin

›Aspirin for primary prevention only

›Risk of rebleeding likely outweighs cardiovascular benefit

›Consider permanent discontinuation

›Dual antiplatelet therapy (DAPT)

›Do not stop aspirin in high thrombotic risk patients (recent stent)

›Resume P2Y12 inhibitor as soon as hemostasis confirmed

›Cardiology consultation for complex antithrombotic decisions

›Anticoagulants (warfarin, DOACs)

›Resume when clinically indicated based on thromboembolic risk

›General guidance: within 7–15 days post-bleed with PPI co-therapy

›Reverse active anticoagulation during acute hemorrhage

›Warfarin: vitamin K 10 mg IV + 4-factor PCC

›Dabigatran: idarucizumab 5 g IV

›Factor Xa inhibitors: andexanet alfa or 4-factor PCC

09Special Populations/sp68

Pregnancy

›Epidemiology in pregnancy

›UGIB in pregnancy is uncommon but high-stakes

›Hyperemesis gravidarum increases risk of Mallory-Weiss tear

›Peptic ulcer disease may improve in first and second trimesters

›Gastric acid secretion reduced due to elevated progesterone

›Diagnostic considerations

›Endoscopy is safe in all trimesters when clinically indicated

›Second trimester preferred for elective procedures

›Fetal monitoring required perioperatively

›Avoid CT with contrast if avoidable in first trimester

›MR enterography as alternative if small bowel source suspected

›POCUS preferred for bedside assessment

›Treatment modifications

›PPI therapy: omeprazole and pantoprazole are category B (FDA)

›Use lowest effective dose; first trimester avoidance preferred if possible

›Benefit outweighs risk in significant UGIB

›NSAIDs contraindicated in pregnancy (especially third trimester)

›Premature closure of ductus arteriosus

›Erythromycin: use with caution; crosses placenta

›H. pylori eradication: defer to postpartum if non-urgent

›Avoid tetracycline and bismuth in pregnancy

›Restrictive transfusion threshold maintained at Hgb < 7.0 g/dL (70 g/L) in stable patients

›Positioning

›Left lateral decubitus after 20 weeks to relieve aortocaval compression

Geriatric

›Epidemiology

›Age > 60–65 years: highest attributable risk for UGIB at 25%

›In-hospital mortality higher in elderly: up to 10% in those > 80 years

›Polypharmacy is primary driver of increased risk

›Atypical presentation risk

›Syncope without hematemesis as sole presentation

›Altered mental status from acute blood loss

›Absence of tachycardia due to beta-blockers or pacemakers

›Blunted febrile response masking concurrent infection

›Management modifications

›Lower transfusion threshold in cardiovascular disease: Hgb < 8.0 g/dL (80 g/L)

›Volume resuscitation with caution: heart failure and renal impairment risk

›Monitor closely for pulmonary edema

›Renal dosing adjustments for antibiotics

›Fall and delirium prevention during hospitalization

›Complex antithrombotic decisions more common in elderly

›High rates of atrial fibrillation and coronary stents

›Higher rebleeding rates and longer hospital stays compared to younger adults

›PPI safety in elderly

›Long-term PPI use associated with increased fracture risk, hypomagnesemia

›Use lowest effective dose for maintenance; reassess indication annually

Pediatrics

›Epidemiology in children

›UGIB less common than in adults; incidence approximately 1–2 per 10,000

›Most common causes differ by age

›Neonates: hemorrhagic disease of newborn, swallowed maternal blood

›Infants: esophagitis, Mallory-Weiss, vascular malformations

›Children/adolescents: PUD (H. pylori), esophagitis, varices (biliary atresia)

›Diagnostic approach

›Apt-Downey test to differentiate maternal from fetal hemoglobin in neonates

›GBS not validated in pediatric population

›Endoscopy timing and thresholds similar to adults when hemodynamically appropriate

›Treatment differences

›Weight-based dosing for IV PPI

›Pantoprazole 1 mg/kg IV (max 40 mg) once or twice daily

›Esomeprazole 0.5–1 mg/kg IV (max 40 mg)

›Erythromycin 3 mg/kg IV (max 250 mg) as prokinetic

›Transfusion threshold Hgb < 7.0 g/dL (70 g/L) in hemodynamically stable children

›H. pylori eradication in children (if confirmed)

›Amoxicillin 50 mg/kg/day divided BID (max 1 g)

›Clarithromycin 15 mg/kg/day divided BID (max 500 mg)

›PPI 1–2 mg/kg/day divided BID

›14-day course preferred

›Avoid aspirin (Reye syndrome risk)

›NSAIDs with caution; use acetaminophen as first-line analgesic

10Background/b62

Epidemiology

›Prevalence and incidence

›PUD is the most common cause of UGIB: 40–60% of all cases

›Hospitalization rate approximately 67 per 100,000 population in the US

›In-hospital mortality 2–10% (Cochrane 2025, Lancet 2024)

›30-day rebleeding rate after endoscopic treatment approximately 10–15%

›Annual incidence of PUD in Western countries: 0.1–0.3% of population

›Demographic distribution

›Males affected more than females (ratio approximately 2:1)

›Peak incidence 55–65 years

›Declining incidence over past 30 years due to H. pylori eradication and PPI use

›Despite decreasing incidence, mortality remains stable due to aging population

›Etiology distribution

›H. pylori-associated PUD: 20–50% of bleeding PUD cases

›NSAID-associated: approximately 25% of UGIB cases

›Idiopathic (neither H. pylori nor NSAID): increasing proportion

Pathophysiology

›Ulcer formation mechanisms

›Imbalance between aggressive factors and mucosal defense

›Aggressive factors: gastric acid, H. pylori virulence factors, NSAIDs

›Defensive factors: mucus layer, bicarbonate secretion, prostaglandins, mucosal blood flow

›H. pylori mechanisms

›Colonizes gastric antrum and body

›Increases gastrin secretion and acid production

›CagA+ strains associated with higher ulceration and cancer risk

›Disrupts tight junctions and induces inflammatory cascade

›NSAID mechanisms

›COX-1 inhibition reduces prostaglandin synthesis

›Decreases mucus and bicarbonate secretion

›Impairs mucosal blood flow and epithelial restitution

›Topical and systemic effects combine to cause injury

›Bleeding mechanisms

›Ulcer erodes into submucosal blood vessel

›Gastroduodenal artery most commonly involved in posterior duodenal ulcers

›Left gastric artery for gastric body ulcers

›Pseudoaneurysm formation preceding rupture

›Acid prevents platelet aggregation and clot formation at pH < 6.0

›Rationale for high-dose PPI to raise intragastric pH >= 6.0

›Forrest classification correlates with depth of vessel erosion and rebleeding risk

Therapeutic Considerations

›PPI mechanism of action

›Irreversible binding to H+/K+-ATPase pump on parietal cells

›Suppresses acid secretion for 24–48 hours per dose

›High-dose continuous infusion maintains intragastric pH >= 6.0

›pH >= 6.0 required for platelet aggregation and clot stabilization

›Rationale for 80 mg bolus + 8 mg/hr infusion regimen

›Oral vs. IV PPI equivalence for stable patients post-endoscopy

›High-bioavailability oral PPIs may be as effective as IV in non-critical patients

›Endoscopic hemostasis evidence base

›Combination therapy reduces rebleeding vs. monotherapy

›Thermal + injection vs. injection alone: NNT approximately 7

›OTSC as rescue device or primary therapy for high-risk stigmata

›ESGE 2026 Guideline: OTSC recommended for Forrest Ia/IIa as alternative to combination

›Prophylactic embolization post-endoscopy

›Cochrane 2025: prophylactic TAE post-endoscopic control not superior to standard care

›No reduction in rebleeding, mortality, or length of stay

›TAE reserved for actual rebleeding, not prophylaxis

›Somatostatin analogues

›Octreotide not standard of care for non-variceal UGIB

›Role limited to variceal bleeding and bridge to endoscopy

›No benefit demonstrated for PUD-related bleeding

›Secondary prophylaxis post-discharge

›Maintenance PPI for all patients with NSAID requirement and history of UGIB

›H. pylori eradication most important factor to prevent recurrence

›Avoid NSAIDs; use celecoxib (selective COX-2) with PPI if NSAID unavoidable

11Patient Discharge Instructions/pdi28

copy discharge instructions

›Discharge instruction summary for Upper GI Bleed (Peptic Ulcer Disease)

›Diagnosis and what happened

›You were treated for bleeding in the upper part of your digestive tract, most likely from a stomach or duodenal ulcer

›An endoscopy (camera procedure) was performed to find and treat the source of bleeding

›Medications to take

›Take your prescribed acid-blocking medication (proton pump inhibitor) exactly as directed

›Do not stop taking your PPI early even if you feel better

›If prescribed H. pylori antibiotics, complete the full 14-day course

›Medications to avoid

›Do not take ibuprofen, naproxen, aspirin (unless specifically directed by your physician), or other anti-inflammatory medications

›Do not take blood thinners unless your doctor specifically tells you to resume them

›Avoid alcohol; it irritates the stomach lining and increases bleeding risk

›Lifestyle and diet

›Resume eating small, bland meals when you feel able, usually within 24 hours of discharge

›Avoid spicy foods, caffeine, and carbonated drinks during recovery

›Do not smoke; smoking slows ulcer healing and increases rebleeding risk

›Stay well hydrated with water and non-caffeinated fluids

›Follow-up appointments

›Follow up with a gastroenterologist within 1–2 weeks of discharge

›If you had a gastric (stomach) ulcer, a repeat endoscopy is recommended in 8–12 weeks to confirm healing and rule out cancer

›H. pylori eradication should be confirmed with a breath test or stool test at least 4 weeks after finishing antibiotics

›Return to emergency department immediately if you experience

›Vomiting blood or coffee-ground material

›Black, tarry, or bloody stools

›Dizziness, lightheadedness, or fainting

›Severe stomach pain or sudden worsening abdominal pain

›Chest pain or shortness of breath

12References/r24

Guidelines and key sources

›Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. The American Journal of Gastroenterology. 2021. https://doi.org/10.14309/ajg.0000000000001245

›Primary guideline informing management of UGIB and PUD bleeding

›Gralnek IM, Morris J, Laursen SB, et al. Endoscopic Diagnosis and Management of Peptic Ulcer Bleeding: ESGE Guideline Update 2026. Endoscopy. 2026. https://pubmed.ncbi.nlm.nih.gov/42127996

›Current European endoscopy guideline; OTSC and combination therapy recommendations

›Laine L. Upper Gastrointestinal Bleeding Due to a Peptic Ulcer. N Engl J Med. 2016. https://www.nejm.org/doi/full/10.1056/NEJMcp1514257

›Comprehensive clinical review; antithrombotic resumption RCT data

›Lau JYW, Yu Y, Tang RSY, et al. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. N Engl J Med. 2020. https://www.nejm.org/doi/full/10.1056/NEJMoa1912484

›RCT demonstrating no benefit of urgent vs. early endoscopy

›Almadi MA, Lu Y, Alali AA, Barkun AN. Peptic Ulcer Disease. Lancet. 2024. https://pubmed.ncbi.nlm.nih.gov/38885678

›Contemporary PUD epidemiology, pathophysiology, and management review

›Vakil N. Peptic Ulcer Disease: A Review. JAMA. 2024. https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2024.19094

›Scoring systems, risk factors, and H. pylori management overview

›Stanley AJ, Laine L, Dalton HR, et al. Comparison of Risk Scoring Systems for UGIB: International Multicentre Prospective Study. BMJ. 2017. https://pubmed.ncbi.nlm.nih.gov/28053181

›GBS vs. Rockall vs. AIMS65 comparative validation study

›Abraham NS, Barkun AN, Sauer BG, et al. ACG-CAG Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute GI Bleeding. AJG. 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8966740/

›Antithrombotic resumption guidance post-UGIB

›Zetner D, Roost I, Rosenberg J, Andresen K. Prophylactic Transarterial Embolization in Patients With Bleeding Peptic Ulcers Following Endoscopic Control. Cochrane Database. 2025. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD014999.pub2/full

›Systematic review: prophylactic TAE not superior to standard care

›Nagpal P, Dane B, Aghayev A, et al. ACR Appropriateness Criteria: Nonvariceal Upper Gastrointestinal Bleeding: 2024 Update. J Am Coll Radiol. 2024. https://doi.org/10.1016/j.jacr.2024.08.021

›Imaging algorithm and CTA appropriateness criteria

›Tarasconi A, Coccolini F, Biffl WL, et al. Perforated and Bleeding Peptic Ulcer: WSES Guidelines. World J Emerg Surg. 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947898/

›Surgical management and escalation guidance

›Long B, Gottlieb M. Emergency Medicine Updates: Upper Gastrointestinal Bleeding. Am J Emerg Med. 2024. https://pubmed.ncbi.nlm.nih.gov/38723362

›Emergency medicine-focused clinical update and pearls

Evidence & Review

Evidence & Review