Reasoning GP · Diagnostic Compass · decision tree

Haematemesis1 PAGE

Vomiting blood, coffee-grounds or melaena in an adult: 999, same-day hospital, or a mimic?

NICE CG141 · NG12 (Apr 2026) · CG184 · NG253
QS38 · Glasgow-Blatchford · BSG care bundle 2020
Reviewed Oct 2026 · next review Apr 2027

Applies to: adults vomiting blood or coffee-grounds, or with melaena, in hours, OOH or remote; not children. Suspected upper GI bleeding needs urgent hospital assessment, whatever the look or volume.

Blood vomited

Active fresh red haematemesis, or any with instability: tachycardia (masked by beta-blockers), hypotension, postural drop, cool peripheries, confusion · Syncope · melaena with compromise · falling consciousness · airway soiling · Known varices or cirrhosis with any bleed, even small · Severe chest or epigastric pain + vomiting, surgical emphysema or peritonism · aortic graft + any GI bleed · 60+ with comorbidity: low threshold

Emergency?

YES

CALL 999

Pre-alert "varices suspected"; name any graft. ABCDE, recovery position, never unobserved; oxygen to need; IV only if no delay; nil by mouth. Record time and volume. Do not delay for bloods, a PPI or history.

Recent haematemesis, settled (GBS needs bloods) · new melaena, even if well · Coffee-grounds + risk: 60+, cardiac, renal or respiratory disease, anaemia, immunosuppressed, alone · Anticoagulant or antiplatelet with haematemesis or coffee-grounds · Uncertain: unwitnessed, vague or remote account; unexplained coffee-grounds · Dysphagia at any age, or 55+ with weight loss + upper abdominal pain, reflux or dyspepsia

Same day or cancer pathway?

YES

SAME DAY · CANCER PATHWAY

Same-day hospital or admission; withhold the next DOAC dose, hand over drug, dose, last dose. Dysphagia or 55+: suspected cancer pathway referral (NG12); active bleeding overrides, admit today.

Bleed, mimic or uncertain?

Ulcerepigastric pain, NSAID, aspirin

Stop the NSAID; no PPI before endoscopy.
Secondary-prevention aspirin: do not stop permanently yourself; DAPT: specialist.

Varicespainless, large volume, liver

999; transfer is the treatment.
Newly suspected cirrhosis → hepatology after the episode.

Mallory-Weissretching first

Only diagnosed at endoscopy; still same-day hospital.
Self-induced vomiting → consider eating disorder.

Benign mimicnose, teeth, haemoptysis, food

Demonstrated source, stable, no melaena → treat the source.
No PPI, antibiotics or eradication testing.

EVERY PATIENT

Tests that change management

Pulse, BP lying and standing, RR, SpO₂, temperature, capillary refill, GCS, NEWS2.
Liver stigmata, abdomen, nose and mouth; PR only if history equivocal.
FBC, U&E, LFTs, clotting, group & save only if no delay; send with the patient.
Not from primary care: OGD, CT, FIT or faecal occult blood.

Safety-net · follow up

999: vomit blood again, faint or feel faint on standing, severe chest or tummy pain.
Today: black, sticky, smelly stool, coffee-ground vomit, more breathless or pale.
Remote: blood not witnessed, obs not possible or support unsure → safer destination; after discharge review within 1 week.

Never: Reassure because it stopped, was a teaspoon, followed retching, or was coffee-grounds · Trust a normal Hb or a normal pulse on a beta-blocker · Label "just gastritis" or "swallowed nosebleed" without positive evidence

Reasoning GP · Haematemesis · decision tree · v1.0 · Oct 2026 · Full algorithm: gpreasoning.uk/tools/algorithms/haematemesis.htmlDecision support, not a substitute for clinical judgement. Check doses in the SPC and your local formulary.