REASONING GP · Clinical algorithm · Quick reference

Haematemesis and upper GI bleeding in adults — triage and diagnostic approach

Daytime GP and OOH/111, face-to-face or remote. Resuscitate, risk-assess and transfer; confirm the bleed is real and upper GI. Ongoing eradication, gastroprotection and follow-up are in the full Steps pathway.

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AdultsGP + OOHDisposal firstv1.0 · Sep 2026

Core rule. Confirmed haematemesis or melaena is an acute admission, whatever the patient looks like and whatever the volume. Do not risk-assess towards discharge in primary care: NICE CG141 requires formal risk assessment and endoscopy within 24 hours of admission, immediately after resuscitation if unstable. A normal haemoglobin, a settled bleed and a "known Mallory-Weiss" do not make it safe. Blood tests must never delay transfer.

Before any history: is this an emergency now? Stop the consultation and call 999 if any of these is present

Active fresh red haematemesis · shock or postural hypotension (systolic <100 mmHg, pulse >100, capillary refill >2 s, cool peripheries) · syncope or collapse with the bleed · melaena with haemodynamic compromise · known varices or chronic liver disease · reduced or falling consciousness · airway soiling. ABCDE, lie flat, high-flow oxygen, wide-bore IV access and crystalloid if available, nil by mouth, recovery position if vomiting. Record time and estimated volume of the last bleed. Do not delay transfer for bloods, a PPI, a CT request or a fuller history.

Define the bleed in four lines Enough to place the patient in the table below

Time

Time of first and last episode. Number of episodes. Still bleeding now? Volume in household terms (teaspoon, cupful, bowlful). Retching before blood (Mallory-Weiss) or blood with the first vomit.

Character

Fresh red, clots, or brown coffee-grounds. Melaena: black, tarry, offensive stool. Fresh red PR blood with haematemesis means very brisk upper GI bleeding, not a lower GI source.

Context

NSAID, aspirin, steroid, SSRI, bisphosphonate (include supermarket ibuprofen) · anticoagulant or antiplatelet · alcohol and known cirrhosis or previous banding · previous ulcer, H. pylori, OGD or GI bleed · previous aortic graft · age ≥60 and comorbidity.

Associated

Dizziness, syncope, breathlessness, chest pain · epigastric pain before the bleed · dysphagia, weight loss, early satiety · jaundice, ascites, confusion · mimics: epistaxis, haemoptysis, dental bleeding, red food or drink, iron or bismuth.

Red-flag screen: trigger → concern → destination → what to do before handover One row is enough; do not add up reassuring features

Trigger / red flag	Leading concern · destination	Do now · do not delay
Active fresh haematemesis, or any haematemesis with shock: systolic <100 mmHg, pulse >100, postural drop >20 mmHg, cool mottled peripheries, confusion.	Major upper GI haemorrhage 999 now	Lie flat, oxygen, wide-bore IV access, crystalloid if available, nil by mouth. Record time and volume of last bleed, drug and alcohol history, and observations for handover. Do not give a PPI before endoscopy (CG141) and do not wait for bloods.
Known varices, cirrhosis or liver stigmata: jaundice, ascites, spider naevi, splenomegaly, encephalopathy — with any haematemesis, even small volume.	Variceal haemorrhage 999 now	Highest-mortality group; painless and can be catastrophic. Pre-alert the receiving team that varices are suspected — terlipressin, prophylactic antibiotics and banding within 24 h are hospital actions. Do not observe at home.
Melaena: black, tarry, offensive stool, with or without vomiting. Confirm by rectal examination if the history is equivocal.	Upper GI bleed of ≥50 ml Same-day admission 999 if compromised	Patients do not volunteer this — ask specifically: "black, sticky, like tar, with a strong smell". Iron and bismuth blacken stool but do not make it tarry or offensive. A well-looking patient with melaena still goes in today.
Anticoagulated or on antiplatelet therapy: DOAC, warfarin, clopidogrel, dual antiplatelet — with haematemesis or coffee-grounds.	Uncontrollable bleeding · reversal needed Same-day admission	Record drug, dose, last dose time and indication; INR if warfarinised and immediately available, but do not delay transfer for it. Do not stop or restart anticoagulation on your own initiative — that is a specialist decision after haemostasis.
Coffee-ground vomit in a higher-risk patient: age ≥60, significant cardiac, renal or respiratory disease, anaemia, immunosuppression, or living alone without support.	Ongoing or recurrent bleeding with poor physiological reserve Same-day admission	Age and comorbidity, not the volume vomited, predict death. A normal haemoglobin in the first hours means nothing — haemodilution has not yet happened. Take FBC, U&Es, LFTs, clotting and group & save, and send them with the patient.
Dysphagia at any age, or age ≥55 with weight loss plus upper abdominal pain, reflux or dyspepsia — with or without bleeding.	Oesophageal or gastric cancer Urgent direct-access OGD within 2 weeks · NICE NG12	Use the urgent suspected-cancer route and state the alarm feature in the request. Active bleeding overrides this: admit today and the inpatient scope serves both purposes. Haematemesis alone in a stabilised patient is a "consider non-urgent direct-access OGD" criterion (NG12).
Severe chest or epigastric pain with vomiting, subcutaneous emphysema, or pain after violent retching.	Boerhaave oesophageal perforation · peptic perforation 999 now	Peritonism or shock with vomiting is a surgical emergency, not a bleeding problem. Nil by mouth, IV access, transfer. Do not attribute severe pain to "gastritis" after an episode of vomiting blood.
Previous abdominal aortic graft with any GI bleed, however small ("herald bleed").	Aorto-enteric fistula 999 now, state the graft	Rare, and the definitive bleed is usually fatal within hours. Pre-alert and name the graft explicitly. Never plan outpatient investigation.
Is it actually upper GI blood? Swallowed epistaxis (especially anticoagulated older patients), haemoptysis (frothy, coughed), dental or oropharyngeal bleeding, red food, drink or dye.	Benign mimic Primary care	Look in the nose and mouth before accepting the diagnosis. If a genuine non-GI source is found and the patient is stable, treat that source. If any doubt remains, treat as an upper GI bleed and admit.

Trigger / red flag

Leading concern · destination

Do now · do not delay

Active fresh haematemesis, or any haematemesis with shock: systolic <100 mmHg, pulse >100, postural drop >20 mmHg, cool mottled peripheries, confusion.

Major upper GI haemorrhage
999 now

Lie flat, oxygen, wide-bore IV access, crystalloid if available, nil by mouth. Record time and volume of last bleed, drug and alcohol history, and observations for handover. Do not give a PPI before endoscopy (CG141) and do not wait for bloods.

Known varices, cirrhosis or liver stigmata: jaundice, ascites, spider naevi, splenomegaly, encephalopathy — with any haematemesis, even small volume.

Variceal haemorrhage
999 now

Highest-mortality group; painless and can be catastrophic. Pre-alert the receiving team that varices are suspected — terlipressin, prophylactic antibiotics and banding within 24 h are hospital actions. Do not observe at home.

Melaena: black, tarry, offensive stool, with or without vomiting. Confirm by rectal examination if the history is equivocal.

Upper GI bleed of ≥50 ml
Same-day admission 999 if compromised

Patients do not volunteer this — ask specifically: "black, sticky, like tar, with a strong smell". Iron and bismuth blacken stool but do not make it tarry or offensive. A well-looking patient with melaena still goes in today.

Anticoagulated or on antiplatelet therapy: DOAC, warfarin, clopidogrel, dual antiplatelet — with haematemesis or coffee-grounds.

Uncontrollable bleeding · reversal needed
Same-day admission

Record drug, dose, last dose time and indication; INR if warfarinised and immediately available, but do not delay transfer for it. Do not stop or restart anticoagulation on your own initiative — that is a specialist decision after haemostasis.

Coffee-ground vomit in a higher-risk patient: age ≥60, significant cardiac, renal or respiratory disease, anaemia, immunosuppression, or living alone without support.

Ongoing or recurrent bleeding with poor physiological reserve
Same-day admission

Age and comorbidity, not the volume vomited, predict death. A normal haemoglobin in the first hours means nothing — haemodilution has not yet happened. Take FBC, U&Es, LFTs, clotting and group & save, and send them with the patient.

Dysphagia at any age, or age ≥55 with weight loss plus upper abdominal pain, reflux or dyspepsia — with or without bleeding.

Oesophageal or gastric cancer
Urgent direct-access OGD within 2 weeks · NICE NG12

Use the urgent suspected-cancer route and state the alarm feature in the request. Active bleeding overrides this: admit today and the inpatient scope serves both purposes. Haematemesis alone in a stabilised patient is a "consider non-urgent direct-access OGD" criterion (NG12).

Severe chest or epigastric pain with vomiting, subcutaneous emphysema, or pain after violent retching.

Boerhaave oesophageal perforation · peptic perforation
999 now

Peritonism or shock with vomiting is a surgical emergency, not a bleeding problem. Nil by mouth, IV access, transfer. Do not attribute severe pain to "gastritis" after an episode of vomiting blood.

Previous abdominal aortic graft with any GI bleed, however small ("herald bleed").

Aorto-enteric fistula
999 now, state the graft

Rare, and the definitive bleed is usually fatal within hours. Pre-alert and name the graft explicitly. Never plan outpatient investigation.

Is it actually upper GI blood? Swallowed epistaxis (especially anticoagulated older patients), haemoptysis (frothy, coughed), dental or oropharyngeal bleeding, red food, drink or dye.

Benign mimic
Primary care

Look in the nose and mouth before accepting the diagnosis. If a genuine non-GI source is found and the patient is stable, treat that source. If any doubt remains, treat as an upper GI bleed and admit.

Safety rule. "It has stopped", "it was only a teaspoon", "it was after retching" and a normal haemoglobin are not discharge criteria. A Glasgow-Blatchford score of 0 identifies very low risk, but it needs blood results and most UK units admit at ≥1 — so in primary care the score informs the handover, not the decision to keep the patient at home. Self-induced vomiting with haematemesis: consider an eating disorder and assess physical risk.

Focused examination and investigation Only after the emergency question is answered; remote assessment that cannot deliver these is an escalation criterion

Observations

Pulse, BP lying and standing, RR, SpO₂, temperature, capillary refill, GCS, NEWS2. A postural drop >20 mmHg is the earliest reliable sign of significant loss. Repeat after any further bleed.

System examination

Pallor, sweating, confusion. Abdomen: epigastric tenderness, mass, peritonism, hepatomegaly, splenomegaly, ascites. Rectal examination to confirm melaena where the history is unclear.

Targeted signs

Liver stigmata: jaundice, spider naevi, palmar erythema, caput medusae, asterixis. Nose and oropharynx for a bleeding point. Surgical scars and previous graft sites. Signs of malignancy: cachexia, epigastric mass, Virchow's node.

Investigations

Question-led only, and never instead of transfer: FBC, U&Es (raised urea with normal creatinine supports an upper source), LFTs, clotting/INR, group & save — sent with the patient. Not from primary care: OGD, CT, FIT (a colorectal tool with no role here), faecal occult blood.

Colour is semantic: red = emergency now · amber = same-day acute assessment · blue = define/assess · green = benign diagnosis established · purple = uncertain / specialist route. Continued on page 2: classification, cause classifier, routine referral, primary-care treatment, endpoint.

REASONING GP · Haematemesis and upper GI bleeding in adults — triage and diagnostic approach

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Classify: three exits, not two A settled bleed is not a benign bleed

Acute upper GI bleed

Confirmed haematemesis or melaena, or coffee-grounds with any red flag, comorbidity, anticoagulation or liver disease. Output: name the suspected source (ulcer, varices, malignancy), use the destination above, and hand over volume, timings, drugs and observations.

Benign mimic established

A demonstrated non-GI source — epistaxis, dental bleeding, haemoptysis with a respiratory cause — or clearly identified red food or drink, in a stable patient with no melaena and normal observations. Output: record the source, treat it, and give the written safety-net below.

Unclassified / uncertain

Reported blood not witnessed, vague history, remote assessment, unreliable account, or coffee-grounds with no clear cause in an otherwise well younger adult. Output: do not default to "gastritis". State the uncertainty; the safe default is same-day assessment.

Cause classifier once the patient is safe Shapes the handover and the follow-up, not the decision to admit

Peptic ulcer (commonest)

Epigastric pain preceding the bleed; NSAID, aspirin, steroid or SSRI exposure; H. pylori. Duodenal more often than gastric. Posterior duodenal ulcers erode the gastroduodenal artery and bleed briskly.

Erosive gastritis or oesophagitis

NSAIDs, alcohol, reflux. Typically low-volume coffee-grounds rather than fresh blood. Still requires the acute pathway when bleeding is confirmed.

Varices

Painless, large volume, in cirrhosis or portal hypertension. Previous banding, alcohol excess, hepatitis B or C. Highest mortality; needs pre-alert and hepatology follow-up with secondary prophylaxis.

Mallory-Weiss tear

Forceful retching, coughing or vomiting then streaks or small volumes of blood. Usually self-limiting — but the diagnosis is made after endoscopy, never in the surgery, and it is the classic false-reassurance trap.

Upper GI malignancy

Dysphagia, progressive weight loss, early satiety, iron-deficiency anaemia, epigastric mass. Requires OGD on the NG12 route even after the acute episode is managed.

Do not label by default

"Just gastritis", "only a Mallory-Weiss" and "swallowed nosebleed" need positive evidence. Also consider: Dieulafoy lesion, angiodysplasia, gastric antral vascular ectasia, aorto-enteric fistula, coagulopathy, and nicorandil- or hydroxycarbamide-related ulceration.

Refer routinely from this consultation Not same-day, not 999 — the cases that leave by letter

NG12: consider non-urgent direct-access OGD for haematemesis in a patient whose bleeding has clearly stopped and who is otherwise stable; and in people aged ≥55 with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin, raised platelets with an upper GI symptom, or nausea and vomiting with weight loss, reflux, dyspepsia or upper abdominal pain. Routine gastroenterology (CG184): recurrent ulcer despite eradication and a full PPI course, refractory reflux, or an unavoidable long-term NSAID after a bleed. Routine hepatology: newly suspected cirrhosis or portal hypertension for variceal surveillance and prophylaxis. Interim advice: stop the NSAID or aspirin unless it is essential secondary prevention, and give the written safety-net below. Not routine: dysphagia at any age, or ≥55 with weight loss plus an upper GI symptom — that is the 2-week urgent OGD route on page 1.

The only treatment decisions that belong in this consultation Everything else is in the management pathway

Active bleed, shock, varices, melaena

Transfer is the treatment. Lie flat, high-flow oxygen, wide-bore IV access and crystalloid if available, nil by mouth. Do not give a PPI before endoscopy (CG141: no benefit on mortality, re-bleeding or surgery, and it may obscure findings). Do not sedate; do not give oral fluids; do not delay the ambulance for bloods or a cannula.

Anticoagulant or antiplatelet in situ

Withhold the next dose and hand over drug, dose, last-dose time and indication. Reversal (vitamin K, PCC, idarucizumab, andexanet) is a hospital decision. Do not permanently stop aspirin taken for secondary prevention on your own initiative — thrombotic risk rises and most patients resume with gastroprotection once haemostasis is secure.

Culprit drugs

Stop the NSAID or aspirin now unless it is essential secondary prevention (name it in the referral); stop bisphosphonates; note steroids and SSRIs. Document what was stopped and why, so the discharge summary does not silently reinstate it.

Confirmed benign mimic only (demonstrated epistaxis, dental or oropharyngeal bleeding, stable, no melaena)

Treat the source: nasal pressure and topical measures, dental referral, review anticoagulation intensity. Give the written safety-net and a named review. No PPI, no antibiotics, no eradication testing at this visit.

Established ulcer, after discharge

Full-dose PPI (omeprazole 20–40 mg daily or lansoprazole 30 mg daily) for 4–8 weeks per CG184, then H. pylori test-and-treat. Test at least 2 weeks after the PPI stops (and 4 weeks after antibiotics) or the result is falsely negative; after a bleeding ulcer, eradication must be confirmed by urea breath test. This belongs to the follow-up consultation, not the acute one.

Endpoint and documentation Finish with one of four conclusions and a named owner

1 · Time-critical bleed

999 or acute route taken; suspected source, time and volume of each bleed, observations including postural BP, GCS, alcohol and liver history, anticoagulant with last dose time, bloods sent with the patient.

2 · Bleed possible

Same-day admission arranged; state what is being excluded, who was spoken to, and the deadline for assessment. Record that the patient was advised nil by mouth and how they will travel.

3 · Benign mimic established

The demonstrated source, the observations that support stability, absence of melaena on direct questioning or examination, drugs stopped, safety-net given, review owner and date.

4 · Unclassified

Uncertainty stated, exclusions outstanding, and the default chosen — same-day assessment. Record why, and who reviews if the patient declines.

Why a benign conclusion is safe today, in one line: a positively identified non-GI source · no melaena on direct questioning or rectal examination · normal observations including postural BP · no anticoagulant, liver disease or significant comorbidity · written safety-net given and an agreed review. Safety-net wording: call 999 if you vomit blood again, faint or feel faint on standing, or develop severe chest or tummy pain; contact us the same day if your stool turns black, sticky and strong-smelling, if you vomit anything that looks like coffee grounds, or if you become more breathless or pale.

OOH / remote limitation. Convert to face-to-face or emergency assessment if the blood was not witnessed by a clinician; volume or timing cannot be established; observations, postural BP or a rectal examination cannot be obtained; the patient is anticoagulated, has liver disease or significant comorbidity; the caller is not the patient; or transport, support at home or timely review cannot be guaranteed. Under time pressure the default is the safer destination.

Clinical decision support only; follow local emergency-transfer and referral policies and check doses against the current BNF. Source hierarchy: NICE guidelines first, then BNF/MHRA for doses and safety, then national specialty guidance. Sources: NICE CG141 Acute upper gastrointestinal bleeding over 16s · NG12 Suspected cancer: recognition and referral · CG184 Gastro-oesophageal reflux disease and dyspepsia in adults · NICE guidance — Dyspepsia — proven peptic ulcer and Helicobacter pylori · NG51 Sepsis · BNF · Glasgow-Blatchford score (as adopted in CG141) · BSG care bundle for acute upper GI bleeding. Review after any guidance or medicines-safety update, otherwise every 6 months. © Reasoning GP · gpreasoning.uk