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gi.ugib.core.v1PRODUCTION
gi.ugib.core.v1

Upper GI Bleeding

gastroenterologyacuteadult
Hard-required inputs
0 / 13
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm UGIB scope; remember some apparent UGIB is actually nasal/oropharyngeal swallowed blood — and ~15% of melena can be lower source (ACG 2021 Laine)

Inputs
1
Actions
0
Advance rule
Set
Advance when

upper source plausible

Patient inputs (18)

AIMS-65 age >65 component; mortality stratification (Saltzman 2011)

SBP <90 hemodynamically unstable; AIMS-65 component (ACG 2021 Laine)

Tachycardia / shock index; GBS component (ACG 2021 Laine)

Variceal pathway — Baveno VII vasoactive + abx prophylaxis

PUD pathway; PPI co-prescription (ACG 2021 Laine)

Reversal decision; aspirin continuation for secondary CV prevention (ACG 2021 Laine)

GBS component; transfusion threshold (Hgb 7 per ACG 2021 / TRIGGER)

Coagulopathy management (ACG 2021 Laine)

AIMS-65 INR >1.5; warfarin reversal threshold

GBS component; elevated BUN:Cr suggests upper source (ACG 2021 Laine)

Renal function; contrast safety; medication dosing (ACG 2021)

AIMS-65 albumin <3

Diagnostic + therapeutic; Forrest classification

MELD if variceal source; cirrhosis severity (Baveno VII 2022)

Localize bleed if EGD non-diagnostic / massive (ACG 2021 Laine)

Aortoenteric fistula — emergent vascular surgery (ACG 2021)

Mallory-Weiss tear pattern (ACG 2021)

Perfusion marker for shock (ESGE 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateninghemodynamic_instability_persistent
    SBP <90 or HR >110 persistent despite 2L crystalloid + initial transfusion (ACG 2021 Laine)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningaortoenteric_fistula_suspected
    Massive UGIB in patient with prior aortic graft or AAA repair (ACG 2021 Laine)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveregbs_ge_6_within_24h_egd
    Glasgow-Blatchford Score >=6 on arrival (ACG 2021 Laine)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresuspected_variceal_bleed
    Hematemesis + known cirrhosis OR stigmata of chronic liver disease (Baveno VII 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereanticoagulation_reversal_active_bleed
    Active UGIB on warfarin INR >1.5 or DOAC or recent thrombolysis (ACG 2021 Laine)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererebleed_post_EGD
    Hgb drop >=2 g/dL OR recurrent hematemesis or melena within 72h of index EGD (ACG 2021 Laine)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehepatic_encephalopathy_post_variceal_bleed
    New AMS or asterixis or sleep reversal in cirrhotic post-variceal bleed (Baveno VII 2022; AASLD 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

UGIB acute regimen — non-variceal vs variceal pathways (ACG 2021 + Baveno VII)
axis: ugib_acutestep 1 - Step 1 — Resuscitation and triage (all UGIB)
Selected step "Step 1 — Resuscitation and triage (all UGIB)" — Hematemesis / coffee-ground / melena / acute Hgb drop
  • normal_saline_or_LR
    first line
    crystalloid
    500-1000 mL IV bolus then titrate • IV • per response
    triggers: hemodynamic_instability
    Initial volume resuscitation; LR generally preferred over NS in massive resuscitation (ACG 2021 Laine; ESGE 2021)
    rxcui 9863
  • packed_red_blood_cells
    first line
    blood_product
    1-2 units • IV • per response
    triggers: Hgb_<7, Hgb_<8_with_CV_disease, ongoing_active_bleed
    Restrictive transfusion threshold Hgb <7 (TRIGGER/Villanueva 2013); <8 if ACS/CAD

ed playbook — drug actions (7)

  1. 1. crystalloid resuscitation
    500-1000 mL bolus IV LR • IV • PRN
    trigger: Hemodynamic instability
    Initial volume restoration (ACG 2021 Laine)
  2. 2. PRBC transfusion (restrictive)
    1-2 units • IV • PRN
    trigger: Hgb <7 (or <8 with CAD/ACS)
    Villanueva 2013
  3. 3. pantoprazole IV
    80 mg bolus then 8 mg/h × 72h post-EGD if high-risk Forrest • IV • continuous
    trigger: Suspected non-variceal UGIB with high-risk endoscopic stigmata
    ACG 2021
  4. 4. octreotide IV (variceal pathway)
    50 mcg bolus then 50 mcg/h × 3-5 days • IV • continuous
    trigger: Known cirrhosis OR suspected variceal bleed
    Baveno VII
  5. 5. ceftriaxone IV (variceal pathway)
    1 g IV daily × 7 days • IV • daily
    trigger: Cirrhosis with UGIB
    Baveno VII Class I — reduces SBP, rebleed, mortality
  6. 6. erythromycin IV prokinetic
    250 mg IV • IV • single dose 30-90 min pre-EGD
    trigger: Active hematemesis with clot burden expected
    Improves endoscopic visualisation (ACG 2021 Laine; ESGE 2021)
  7. 7. anticoagulation reversal
    Vit K 10 mg IV + 4F-PCC 25-50 IU/kg; idarucizumab 5 g (dabigatran); andexanet (Xa inhibitors) • IV • one-time
    trigger: Active bleed on anticoagulant
    Per drug-specific reversal (ACG 2021 Laine)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Hematemesis (red blood or coffee-ground); Melena (black tarry stools); Syncope / presyncope with GI blood loss.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Upper GI Bleeding** (gi.ugib.core.v1).
Phenotype framing: PUD > varices > Mallory-Weiss > erosive esophagitis/gastritis > Dieulafoy > Cameron lesion > malignancy > angiodysplasia > aortoenteric fistula > hemobilia > epistaxis swallowed blood
Scope: Confirm UGIB scope; remember some apparent UGIB is actually nasal/oropharyngeal swallowed blood — and ~15% of melena can be lower source (ACG 2021 Laine)

No severity triggers fired against current inputs.

Plan

Regimen axis: **UGIB acute regimen — non-variceal vs variceal pathways (ACG 2021 + Baveno VII)** — step "Step 1 — Resuscitation and triage (all UGIB)".
1. normal_saline_or_LR 500-1000 mL IV bolus then titrate IV per response (crystalloid, first line) — Initial volume resuscitation; LR generally preferred over NS in massive resuscitation (ACG 2021 Laine; ESGE 2021)
2. packed_red_blood_cells 1-2 units IV per response (blood_product, first line) — Restrictive transfusion threshold Hgb <7 (TRIGGER/Villanueva 2013); <8 if ACS/CAD

Setting playbook (ed) — Resuscitate, risk-stratify with Glasgow-Blatchford, initiate empiric pharmacotherapy (PPI ± octreotide+ceftriaxone for variceal), reverse anticoagulation, arrange EGD within 24h
3. crystalloid resuscitation 500-1000 mL bolus IV LR IV PRN — Hemodynamic instability (Initial volume restoration (ACG 2021 Laine))
4. PRBC transfusion (restrictive) 1-2 units IV PRN — Hgb <7 (or <8 with CAD/ACS) (Villanueva 2013)
5. pantoprazole IV 80 mg bolus then 8 mg/h × 72h post-EGD if high-risk Forrest IV continuous — Suspected non-variceal UGIB with high-risk endoscopic stigmata (ACG 2021)
6. octreotide IV (variceal pathway) 50 mcg bolus then 50 mcg/h × 3-5 days IV continuous — Known cirrhosis OR suspected variceal bleed (Baveno VII)
7. ceftriaxone IV (variceal pathway) 1 g IV daily × 7 days IV daily — Cirrhosis with UGIB (Baveno VII Class I — reduces SBP, rebleed, mortality)
8. erythromycin IV prokinetic 250 mg IV IV single dose 30-90 min pre-EGD — Active hematemesis with clot burden expected (Improves endoscopic visualisation (ACG 2021 Laine; ESGE 2021))
9. anticoagulation reversal Vit K 10 mg IV + 4F-PCC 25-50 IU/kg; idarucizumab 5 g (dabigatran); andexanet (Xa inhibitors) IV one-time — Active bleed on anticoagulant (Per drug-specific reversal (ACG 2021 Laine))

Non-pharmacologic actions:
- NPO (ACG 2021 Laine)
- Two large-bore IV access (ACG 2021)
- NGT lavage no longer routinely indicated (low yield, may cause harm) (ACG 2021 Laine)
- EGD within 24h (within 12h if hemodynamic instability persists despite resuscitation) (ACG 2021 Laine; ESGE 2021)
- Airway protection if hematemesis + altered mentation (intubate before EGD) (ACG 2021)
- IR / surgical consult on standby for refractory bleed (ACG 2021 Laine)

AVOID / contraindication checks:
- Tranexamic acid avoid in UGIB no mortality benefit (HALT IT 2020)
- NSBB hold during acute variceal bleed (Baveno VII 2022 de Franchis)
- NSAID avoid in UGIB bleeding risk (ACG 2021 Laine)
- Antiplatelet aspirin continuation for secondary CV prevention (ACG 2021 Laine)
- PPI continue post endoscopy high risk lesion (ACG 2021 Laine; ESGE 2021)

Monitoring

Regimen monitoring:
- serial Hgb q6-8h first 24h (ACG 2021 Laine)
- lactate clearance q6h if shock (ESGE 2021)
- INR post reversal q6-12h (ACG 2021 Laine)
- rebleed surveillance 48-72h (ACG 2021 Laine)
- hepatic encephalopathy watch in variceal (Baveno VII 2022)
- SBP monitoring in cirrhotic UGIB (Baveno VII 2022)

Setting (ed) monitoring:
- SpO2 + telemetry continuous (ACG 2021)
- Serial Hgb q6h (ACG 2021 Laine)
- Vitals q1h until stable (ACG 2021)
- Lactate clearance q6h if shock (ESGE 2021)
- Hourly UOP if shock (ACG 2021)

Follow-up plan: Repeat EGD 6-8w for ulcer/malignancy; HP eradication confirmation 4w; variceal band ligation series q2-4w + secondary NSBB prophylaxis; anticoag resumption with cardiology; GI clinic 2-4w; iron studies
- Close-out criterion: follow-up scheduled

Monitoring phase: Serial Hgb q6-8h, vitals q1-4h, hourly UOP if shock, lactate clearance q6h, stool color/output, coags post-reversal, rebleeding watch 48-72h, hepatic encephalopathy watch in variceal

Disposition

Current setting: ed — Resuscitate, risk-stratify with Glasgow-Blatchford, initiate empiric pharmacotherapy (PPI ± octreotide+ceftriaxone for variceal), reverse anticoagulation, arrange EGD within 24h

Disposition criteria:
- Discharge home: GBS 0-1, no syncope, no comorbidity, reliable follow-up (ACG 2021 Laine; ESGE 2021)
- Admit ward: GBS >=1 with stable vitals after resuscitation (ACG 2021)
- Admit ICU: variceal bleed, massive transfusion, hemodynamic instability, airway concern (Baveno VII 2022; ACG 2021)

Escalation triggers (move to higher acuity):
- Persistent SBP <90 despite 2L crystalloid + 2 units PRBC then ICU + emergent EGD (ACG 2021 Laine)
- Hematemesis + AMS then intubate before EGD (ACG 2021)
- GBS >=6 + suspected variceal then ICU pathway (Baveno VII 2022)
- Suspected aortoenteric fistula then emergent vascular surgery (ACG 2021)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SBP <90 or HR >110 persistent despite 2L crystalloid + initial transfusion (ACG 2021 Laine)
- [LIFE_THREATENING] Massive UGIB in patient with prior aortic graft or AAA repair (ACG 2021 Laine)
- [SEVERE] Glasgow-Blatchford Score >=6 on arrival (ACG 2021 Laine)

Citations

- ACG 2021 UGIB (Laine) + ESGE 2021 Non-variceal UGIB + Baveno VII 2022 Portal HTN + NICE NG141 (2024 update) + TRIGGER 2015 + HALT-IT 2020 + ABOVE 2024 + PLACE 2024 [PMID:33567467](https://pubmed.ncbi.nlm.nih.gov/33567467/)
- Cited evidence (PMID 11073021) [PMID:11073021](https://pubmed.ncbi.nlm.nih.gov/11073021/)
- Cited evidence (PMID 23281973) [PMID:23281973](https://pubmed.ncbi.nlm.nih.gov/23281973/)

Last reconciled with current guidelines: 2026-05-22.
References
  • ACG 2021 UGIB (Laine) + ESGE 2021 Non-variceal UGIB + Baveno VII 2022 Portal HTN + NICE NG141 (2024 update) + TRIGGER 2015 + HALT-IT 2020 + ABOVE 2024 + PLACE 2024 — PMID:33567467
  • Cited evidence (PMID 11073021) — PMID:11073021
  • Cited evidence (PMID 23281973) — PMID:23281973