Upper gastrointestinal bleeding — risk scores and management

Definition. Bleeding from a source proximal to the ligament of Treitz, presenting with haematemesis, coffee-ground vomiting or melaena. Mortality in the elderly is 10–15%.

Causes in the elderly. Peptic ulcer is the commonest, followed by erosive gastritis/duodenitis, oesophagitis, varices, Mallory-Weiss tear, angiodysplasia, malignancy and Dieulafoy lesion. Key drugs: NSAIDs, aspirin, anticoagulants, SSRIs and corticosteroids.

Atypical presentation in old age. May present as syncope, falls, confusion, angina or unexplained anaemia rather than overt bleeding. Beta-blockers mask tachycardia, and comorbidity determines mortality more than the volume of blood lost.

Resuscitation. ABC approach, two wide-bore cannulae, crystalloid, group-and-crossmatch, correct coagulopathy (PCC for warfarin, andexanet/idarucizumab where available). Restrictive transfusion at Hb <7 g/dL with a target of 7–9 g/dL; a higher threshold of 8 g/dL is used in cardiovascular disease.

Glasgow-Blatchford Score (GBS) — the pre-endoscopy score of choice. Uses urea, haemoglobin, systolic BP, pulse, melaena, syncope, hepatic disease and cardiac failure. GBS 0–1 identifies very low-risk patients who can be managed as outpatients without early endoscopy.

Other risk scores. Rockall score (age, shock, comorbidity, diagnosis, endoscopic stigmata) predicts rebleeding and mortality; AIMS65 (Albumin <3 g/dL, INR >1.5, altered Mental status, SBP <90, age >65) predicts in-hospital mortality; the ABC score predicts 30-day mortality.

Forrest classification of ulcer stigmata. Ia spurting, Ib oozing, IIa non-bleeding visible vessel, IIb adherent clot, IIc flat pigmented spot, III clean base. Forrest Ia, Ib and IIa require endoscopic therapy (rebleed risk approximately 55%, 43% and 22%); IIc and III need no therapy.

Pharmacotherapy. High-dose IV PPI — 80 mg bolus then 8 mg/hour for 72 hours after successful endoscopic haemostasis. IV erythromycin 250 mg 30–120 minutes before endoscopy improves visualisation. If varices are suspected, add terlipressin and prophylactic ceftriaxone.

Endoscopy. Perform within 24 hours of presentation after resuscitation. For actively bleeding ulcers use combination therapy — adrenaline injection plus a second modality (clip or thermal coagulation); adrenaline alone is inadequate. Haemostatic powder (TC-325) is useful for diffuse or malignant bleeding. Routine second-look endoscopy is not recommended.

Failure and secondary prevention. Rebleeding → repeat endoscopy → transcatheter arterial embolisation (preferred in the frail elderly) → surgery if embolisation fails or is unavailable. Then test and eradicate H. pylori, stop NSAIDs, resume aspirin early (within 3–5 days) when needed for secondary prevention, and continue PPI cover.

AABB 2025 international guideline (Ann Intern Med 2025;178:1469) — based on the MINT trial (NEJM 2023), a liberal transfusion threshold of Hb <10 g/dL is now suggested in acute myocardial infarction with anaemia. This is the key exception to the universal restrictive rule and is directly relevant when an older patient bleeds while having myocardial ischaemia.

Canadian Association of Gastroenterology 2025 guideline (Gastroenterology 2025) provides the first dedicated guidance for non-variceal, non-peptic-ulcer bleeding (angiodysplasia, GAVE, Dieulafoy lesion, Mallory-Weiss). A 2025 individual-patient-data meta-analysis also confirmed TC-325 hemostatic powder is superior to conventional therapy for malignant GI bleeding. Cross-reference: The transfusion thresholds referred to here, including the acute myocardial infarction exception, are covered in full in Question 25.