{
  "schemaVersion": 2,
  "eyebrow": "Gastroenterology",
  "title": "Upper Gastrointestinal Bleeding",
  "summary": "Acute upper gastrointestinal bleeding requires immediate hemodynamic assessment, restrictive but context-sensitive transfusion, pre-endoscopic risk stratification, and endoscopy within 24 hours after resuscitation. Management diverges early for suspected variceal hemorrhage and must balance hemostasis against thrombotic risk from interrupted antithrombotic therapy.",
  "seoDescription": "Point-of-care approach to acute upper gastrointestinal bleeding: resuscitation, transfusion, risk stratification, endoscopy, hemostasis, and antithrombotics.",
  "clinicalQuestion": "How should physicians stabilize, risk-stratify, investigate, and treat acute upper gastrointestinal bleeding?",
  "specialty": "Gastroenterology",
  "audience": "U.S. physicians and medical trainees",
  "tags": [
    "acute upper gastrointestinal bleeding",
    "UGIB",
    "nonvariceal bleeding",
    "peptic ulcer bleeding",
    "variceal hemorrhage",
    "endoscopic hemostasis",
    "Glasgow-Blatchford score"
  ],
  "keyTakeaways": [
    "Resuscitate before endoscopy; reserve prophylactic intubation for severe hematemesis, agitation, or inability to protect the airway rather than routine use. [9]",
    "For nonexsanguinating UGIB, a restrictive red-cell strategy using a hemoglobin threshold near 7 g/dL reduces mortality and rebleeding in trial evidence; individualize in acute coronary syndromes or ongoing massive hemorrhage. [9]",
    "Use the Glasgow-Blatchford score before endoscopy; a score of 0-1 identifies patients who may be suitable for outpatient management. [9]",
    "Perform inpatient endoscopy within 24 hours after resuscitation. In high-risk patients, endoscopy within 6 hours did not improve 30-day mortality or rebleeding versus endoscopy at 6-24 hours. [9]",
    "Treat Forrest Ia, Ib, and IIa peptic-ulcer stigmata endoscopically; epinephrine should not be the sole hemostatic modality. [9]",
    "In suspected variceal bleeding, begin vasoactive therapy and antibiotic prophylaxis before endoscopy; esophageal varices require band ligation. [9]"
  ],
  "sections": [
    {
      "id": "initial-stabilization",
      "eyebrow": "First hour",
      "heading": "Stabilize and identify patients requiring urgent escalation",
      "intro": "Treat hemodynamic instability as a resuscitation problem before a localization problem.",
      "paragraphs": [
        "Establish large-bore peripheral IV access, obtain CBC, metabolic panel, coagulation studies, type and screen/crossmatch, and assess for ongoing hematemesis, shock, altered mentation, cardiac ischemia, cirrhosis, and antithrombotic exposure. A structured airway-breathing-circulation approach is appropriate. Routine prophylactic intubation is not supported by observational meta-analyses and has been associated with more aspiration and pneumonia; reserve it for severe hematemesis, agitation, altered consciousness, or inability to protect the airway, with early anesthesia involvement. [9]",
        "Use crystalloid resuscitation with frequent reassessment. A systolic blood pressure target of 90-100 mm Hg has been suggested in guidance, while persistent hypotension after fluids warrants higher-acuity care. [9] Acute hematemesis with melena is typical, but brisk hematochezia with hemodynamic compromise can represent a massive upper-tract source. [7][9]"
      ],
      "bullets": [
        "Obtain ECG and serial ischemia assessment when clinically indicated, particularly in older patients or those with cardiovascular disease; comorbidity commonly drives outcome after UGIB. [9]",
        "Do not use tranexamic acid routinely: HALT-IT found no reduction in death due to bleeding at 5 days and increased venous thromboembolism. [9]",
        "Consider IV erythromycin 250 mg 30-120 minutes before endoscopy when retained blood or clot is likely to impair visualization; meta-analyses found fewer repeat endoscopies and shorter hospitalization. [9]"
      ],
      "subsections": [],
      "table": {
        "caption": "Initial management decisions in acute UGIB. [9]",
        "columns": [
          "Clinical finding",
          "Immediate action",
          "Key implication"
        ],
        "rows": [
          [
            "Severe hematemesis, agitation, or inability to protect airway",
            "Early anesthesia assessment and endotracheal intubation when necessary. [9]",
            "Avoid routine prophylactic intubation in patients who can protect the airway. [9]"
          ],
          [
            "Hemodynamic instability",
            "Large-bore IV access, crystalloid resuscitation, blood preparation, and monitored/critical-care escalation if hypotension persists. [9]",
            "Endoscopic timing follows physiologic stabilization. [9]"
          ],
          [
            "Suspected cirrhosis/variceal source",
            "Start vasoactive therapy and antibiotic prophylaxis before endoscopy. [9]",
            "Variceal management should not wait for endoscopic confirmation when clinical suspicion is high. [9]"
          ],
          [
            "Ongoing or massive bleeding",
            "Do not rely on the initial hemoglobin concentration alone. [9]",
            "Hemoconcentration during intravascular depletion can mask the severity of blood loss. [9]"
          ]
        ]
      }
    },
    {
      "id": "risk-and-transfusion",
      "eyebrow": "Disposition",
      "heading": "Risk stratification and red-cell transfusion",
      "intro": "Use pre-endoscopic risk assessment to distinguish low-risk outpatient candidates from patients requiring admission and intervention.",
      "paragraphs": [
        "The Glasgow-Blatchford score has the best reported discrimination among commonly used pre-endoscopic scores for need for hospital-based intervention or death. A score of 0 or 1 is the commonly recommended threshold for outpatient management in otherwise appropriate patients. [9] The ABC score predicts mortality across both upper and lower GI bleeding, but it is a mortality tool rather than a validated discharge rule: in validation cohorts, low (≤3), medium (4-7), and high (≥8) ABC scores corresponded to 30-day mortality of 1.0%, 7.0%, and 25%, respectively, in UGIB. [19]",
        "For non-life-threatening bleeding, use a restrictive red-cell transfusion strategy. In a randomized trial of 921 patients, transfusion at hemoglobin below 7 g/dL versus below 9 g/dL was associated with lower 6-week mortality; a meta-analysis of five UGIB trials found lower mortality and rebleeding with restrictive transfusion. [9] Evidence is insufficient to extrapolate this threshold to exsanguinating hemorrhage or acute coronary syndrome, where clinical context and ongoing loss supersede a single laboratory value. [9]"
      ],
      "bullets": [
        "Platelet transfusion evidence is limited; a platelet count of 50 × 10^9/L or less is used in some major-hemorrhage protocols, largely on expert consensus. [9]",
        "The ABC score may help identify high mortality risk but should not replace bedside assessment, hemodynamic trajectory, or UGIB-specific intervention risk assessment. [19]"
      ],
      "subsections": [],
      "table": {
        "caption": "Pre-endoscopic disposition and transfusion framework. [9][19]",
        "columns": [
          "Decision",
          "Supported threshold or finding",
          "Action"
        ],
        "rows": [
          [
            "Very low intervention risk",
            "Glasgow-Blatchford score 0-1. [9]",
            "Consider outpatient management only if clinically stable with reliable follow-up and no other admission indication. [9]"
          ],
          [
            "Mortality stratification",
            "ABC score ≤3, 4-7, or ≥8. [19]",
            "Interpret as low, intermediate, and high mortality strata; do not use alone to determine discharge. [19]"
          ],
          [
            "Red-cell transfusion in nonexsanguinating UGIB",
            "Hemoglobin <7 g/dL in restrictive-strategy trial. [9]",
            "Use a restrictive approach, individualized for active massive bleeding and acute coronary syndromes. [9]"
          ]
        ]
      }
    },
    {
      "id": "endoscopy-and-hemostasis",
      "eyebrow": "Definitive treatment",
      "heading": "Endoscopy within 24 hours and lesion-directed hemostasis",
      "intro": "Endoscopy establishes the source, risk stigmata, and need for definitive endotherapy.",
      "paragraphs": [
        "Patients admitted with UGIB should undergo endoscopy within 24 hours of presentation after adequate resuscitation. [9] In a randomized trial of patients with Glasgow-Blatchford scores of 12 or higher, urgent endoscopy within 6 hours did not reduce 30-day mortality or rebleeding compared with endoscopy at 6-24 hours. [9] Thus, unresolved shock, airway risk, or inadequate resuscitation should not be bypassed solely to achieve very early endoscopy.",
        "For peptic ulcer bleeding, endoscopic therapy is indicated for active spurting or oozing (Forrest Ia/Ib) and nonbleeding visible vessel (Forrest IIa) lesions. Endotherapy reduces further bleeding and surgery versus no endotherapy in these high-risk groups. [9] Management of adherent clot (Forrest IIb) remains an area of guideline variation; endoscopic versus medical management alone are both described. Clean-base and flat pigmented lesions (Forrest III/IIc) do not require endoscopic hemostasis. [9]",
        "Injection, thermal, and mechanical modalities are options for nonvariceal hemostasis, but dilute epinephrine should only be used to improve visualization or provide temporary control before a second modality. Epinephrine monotherapy is inferior to combination treatment for prevention of further bleeding. [9] If endoscopic hemostasis fails or bleeding recurs after repeat endoscopy, involve interventional radiology for transarterial embolization; surgery is a salvage option. [9]"
      ],
      "bullets": [
        "Repeat endoscopy is recommended for recurrent bleeding, manifested by recurrent blood loss, a hemoglobin fall exceeding 20 g/L after stabilization, or recurrent tachycardia/hypotension. [9]",
        "In a randomized trial of rebleeding after initial endoscopic therapy, repeat endoscopy achieved long-term control in 73% and caused fewer complications than surgery. [9]"
      ],
      "subsections": [
        {
          "heading": "Post-endoscopic acid suppression and ulcer-directed follow-up",
          "paragraphs": [
            "After endoscopic treatment of high-risk nonvariceal lesions, high-dose proton-pump inhibitor therapy reduces rebleeding, surgery, and mortality. A commonly studied regimen is omeprazole 80 mg IV bolus followed by 8 mg/hour infusion for 72 hours. [9] High-dose intermittent IV or oral PPI therapy is an evidence-supported alternative to continuous infusion. [9]",
            "After the initial high-dose course, U.S. and international guidance cited in the review supports twice-daily high-dose oral PPI for 2 weeks in patients with high-risk lesions requiring endotherapy. Test for Helicobacter pylori at index endoscopy, but recognize reduced sensitivity of rapid urease testing and histology during acute bleeding; retest after a negative acute-phase test and eradicate if positive. [9]"
          ],
          "bullets": []
        }
      ],
      "table": {
        "caption": "Endoscopic risk stigmata and management for peptic-ulcer bleeding. [9]",
        "columns": [
          "Forrest stigmata",
          "Hemostatic approach",
          "Post-endoscopic implication"
        ],
        "rows": [
          [
            "Ia spurting or Ib oozing",
            "Endoscopic hemostasis required. [9]",
            "High rebleeding risk; give high-dose PPI after successful therapy. [9]"
          ],
          [
            "IIa nonbleeding visible vessel",
            "Endoscopic hemostasis required. [9]",
            "High rebleeding risk; give high-dose PPI after successful therapy. [9]"
          ],
          [
            "IIb adherent clot",
            "Endoscopic versus medical management alone remains debated. [9]",
            "Individualize based on clot removal feasibility, lesion features, and expertise. [9]"
          ],
          [
            "IIc flat pigmented spot or III clean base",
            "No endoscopic hemostasis required. [9]",
            "Standard oral PPI therapy is appropriate after endoscopy. [9]"
          ]
        ]
      }
    },
    {
      "id": "variceal-bleeding",
      "eyebrow": "Cirrhosis",
      "heading": "Suspected variceal hemorrhage requires early empiric pharmacotherapy",
      "intro": "Portal hypertensive bleeding has a distinct early treatment bundle.",
      "paragraphs": [
        "In suspected variceal hemorrhage, start a vasoactive agent at presentation and continue for 2-5 days if variceal bleeding is confirmed. Somatostatin, octreotide, and terlipressin reduce portal pressure; randomized evidence summarized in the review supports improved bleeding control, with no clear difference among agents. [9] The supplied evidence does not provide a U.S. dosing regimen; use current institutional protocols and product-specific labeling.",
        "Give antibiotic prophylaxis promptly in cirrhosis with UGIB. Bacterial infection occurs in 35-66% of patients with cirrhosis and variceal bleeding, and a meta-analysis found lower mortality, rebleeding, and length of stay with empiric antibiotics. Choice should reflect local resistance patterns, with treatment continued for up to 7 days. [9]",
        "Endoscopic band ligation is the preferred treatment for bleeding esophageal varices. Gastric varices require anatomy-specific treatment; tissue adhesive or thrombin injection is used for most gastric variceal patterns, whereas gastric varices contiguous with esophageal varices along the lesser curvature may be banded. [9]"
      ],
      "bullets": [
        "If standard endoscopic therapy fails, balloon tamponade or a self-expanding esophageal stent is a bridge to rescue TIPS, not definitive therapy. [9]",
        "Early preemptive TIPS within 72 hours reduced rebleeding and improved 1-year survival in one trial of selected high-risk patients, although implementation and survival effects have varied across trials. [9]"
      ],
      "subsections": [],
      "table": {
        "caption": "Variceal hemorrhage treatment sequence. [9]",
        "columns": [
          "Phase",
          "Action",
          "Purpose"
        ],
        "rows": [
          [
            "Before endoscopy",
            "Start vasoactive therapy and antibiotic prophylaxis when variceal bleeding is suspected. [9]",
            "Reduce portal pressure and infection-associated rebleeding and mortality risk. [9]"
          ],
          [
            "Endoscopy",
            "Band bleeding esophageal varices; use anatomy-directed therapy for gastric varices. [9]",
            "Achieve definitive endoscopic hemostasis. [9]"
          ],
          [
            "Failure of standard control",
            "Bridge with balloon tamponade or esophageal stent while arranging rescue TIPS. [9]",
            "Temporary hemorrhage control; bridge measures carry substantial complications or rebleeding risk. [9]"
          ]
        ]
      }
    },
    {
      "id": "antithrombotics",
      "eyebrow": "Medication safety",
      "heading": "Manage antithrombotics according to bleeding severity and thrombotic indication",
      "intro": "Avoid reflex discontinuation of secondary-prevention antiplatelet therapy.",
      "paragraphs": [
        "For aspirin used solely for primary prevention, discontinuation after proven UGIB is generally appropriate because absolute vascular benefit is small relative to recurrent bleeding risk. In contrast, continue aspirin used for secondary cardiovascular prevention when feasible. If temporarily withheld for life-threatening bleeding, resume after hemostasis; guideline recommendations cited in the review range from immediate resumption to within 5 days. [9]",
        "In patients receiving dual antiplatelet therapy with coronary stents, obtain urgent cardiology input. If severe bleeding requires interruption, continue aspirin and withhold the P2Y12 inhibitor temporarily, then restart the P2Y12 inhibitor within 5 days. [9]",
        "For severe warfarin-associated UGIB, withhold warfarin and use IV vitamin K plus four-factor prothrombin complex concentrate rather than fresh frozen plasma when reversal is necessary. [9] For direct oral anticoagulants, withholding the agent is generally appropriate except in life-threatening bleeding; idarucizumab and andexanet alfa are reversal options, although the supplied evidence notes cost and potential procoagulant concerns. [9] Reintroduce anticoagulation after hemostasis with individualized consideration of thrombotic risk; European guidance summarized in the review advises warfarin resumption within 7 days. [9]"
      ],
      "bullets": [
        "Do not delay endoscopic hemostasis solely for a moderately elevated INR: a case series found similar rebleeding after endotherapy with INR 1.3-2.7 versus INR below 1.3. [9]",
        "For patients on prasugrel specifically, the FDA label warns that premature discontinuation after ACS/PCI increases stent thrombosis, MI, and death; prasugrel is contraindicated with prior TIA or stroke and should generally be avoided in patients 75 years or older except selected high-risk patients. [1]"
      ],
      "subsections": [],
      "table": {
        "caption": "Antithrombotic decisions in UGIB. [1][9]",
        "columns": [
          "Medication context",
          "Acute management",
          "Restart principle"
        ],
        "rows": [
          [
            "Aspirin, primary prevention",
            "Stop after proven UGIB. [9]",
            "Generally do not resume solely for primary prevention. [9]"
          ],
          [
            "Aspirin, secondary prevention",
            "Continue if possible; if withheld for life-threatening bleeding, resume after hemostasis. [9]",
            "Minimize interruption because stopping aspirin increases cardiovascular risk. [9]"
          ],
          [
            "DAPT with coronary stent",
            "Seek cardiology input; if interruption is unavoidable, continue aspirin and temporarily hold the P2Y12 inhibitor. [9]",
            "Restart P2Y12 therapy within 5 days. [9]"
          ],
          [
            "Warfarin with severe UGIB",
            "Hold warfarin; reverse when necessary with vitamin K plus four-factor PCC. [9]",
            "Reassess thrombotic and rebleeding risk; guidance summarized in the review supports resumption within 7 days after hemostasis. [9]"
          ],
          [
            "DOAC",
            "Withhold; consider idarucizumab or andexanet alfa for life-threatening bleeding. [9]",
            "Restart after hemostasis using individualized thrombotic-risk assessment. [9]"
          ]
        ]
      }
    },
    {
      "id": "diagnostic-pitfalls",
      "eyebrow": "Avoid error",
      "heading": "Avoid common diagnostic and management errors",
      "intro": "The most consequential errors are misclassification, premature endoscopy, and incomplete secondary prevention.",
      "paragraphs": [
        "Do not assign a lower-tract source solely because of hematochezia. Brisk hematochezia with hemodynamic compromise can arise from UGIB, and 11-15% of patients initially thought to have lower GI bleeding ultimately have an upper source. [8][9]",
        "Pre-endoscopic PPI use may decrease the proportion requiring endoscopic therapy at index endoscopy but has not shown a reduction in mortality, rebleeding, or surgery; guideline positions differ, particularly when endoscopy will be delayed. [9] This should not substitute for resuscitation, risk assessment, or timely endoscopy.",
        "After ulcer bleeding, ensure H. pylori assessment and follow-up retesting if initial acute-phase testing is negative. In patients exposed to NSAIDs or antithrombotics, reassess the indication, minimize avoidable bleeding-promoting drugs, and document a restart plan before discharge. Evidence supplied supports the antithrombotic principles above but does not provide a specific gastroprotection regimen for every antithrombotic scenario. [9]"
      ],
      "bullets": [],
      "subsections": [],
      "table": {
        "caption": "High-value pitfalls in acute UGIB. [8][9]",
        "columns": [
          "Pitfall",
          "Why it matters",
          "Corrective action"
        ],
        "rows": [
          [
            "Assuming hematochezia excludes UGIB",
            "Rapid upper-tract bleeding can present with bright-red rectal bleeding and instability. [8][9]",
            "Evaluate for an upper source when clinical features suggest brisk UGIB. [8][9]"
          ],
          [
            "Pursuing urgent endoscopy before stabilization",
            "Endoscopy within <6 hours did not improve mortality or rebleeding over 6-24 hours in high-risk patients. [9]",
            "Resuscitate and secure the airway when indicated before endoscopy. [9]"
          ],
          [
            "Using epinephrine alone for ulcer hemostasis",
            "Epinephrine monotherapy is inferior to combination therapy for preventing further bleeding. [9]",
            "Add a mechanical or thermal modality after injection. [9]"
          ],
          [
            "Stopping secondary-prevention aspirin without a restart plan",
            "Interruption increases major cardiovascular events and mortality risk. [9]",
            "Continue when feasible or resume promptly after hemostasis. [9]"
          ]
        ]
      }
    }
  ],
  "faq": [
    {
      "question": "When should endoscopy be performed for acute upper gastrointestinal bleeding?",
      "answer": "Admitted patients should undergo endoscopy within 24 hours after adequate resuscitation. In high-risk patients, endoscopy within 6 hours did not improve 30-day mortality or rebleeding versus endoscopy at 6-24 hours. [9]"
    },
    {
      "question": "Which patients with upper gastrointestinal bleeding can be managed as outpatients?",
      "answer": "A Glasgow-Blatchford score of 0-1 identifies very-low-risk patients who may be suitable for outpatient management, provided they are stable and have no other reason for admission. [9]"
    },
    {
      "question": "What is the transfusion threshold in upper gastrointestinal bleeding?",
      "answer": "For nonexsanguinating UGIB, restrictive transfusion using a hemoglobin threshold near 7 g/dL is supported by randomized and meta-analytic evidence. Do not apply this rigidly to massive ongoing hemorrhage or acute coronary syndrome. [9]"
    },
    {
      "question": "Should proton-pump inhibitors be started before endoscopy?",
      "answer": "Pre-endoscopic PPIs may reduce the need for endoscopic therapy at index endoscopy but have not reduced mortality, rebleeding, or surgery. Guideline recommendations differ, especially if endoscopy is delayed. [9]"
    },
    {
      "question": "How should recurrent peptic-ulcer bleeding be managed?",
      "answer": "Repeat endoscopy is recommended for recurrent bleeding. If repeat endoscopic therapy fails, proceed to transarterial embolization when available; surgery is reserved for refractory cases. [9]"
    },
    {
      "question": "What should be started before endoscopy when variceal hemorrhage is suspected?",
      "answer": "Start vasoactive therapy and antibiotic prophylaxis promptly before endoscopy. Esophageal varices are treated with band ligation, while gastric-varix therapy depends on anatomy. [9]"
    }
  ],
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      "url": "https://www.bmj.com/content/331/7511/293.2",
      "authors": "www.bmj.com",
      "host": "www.bmj.com"
    },
    {
      "number": 22,
      "title": "Management of Nonvariceal Upper Gastrointestinal Bleeding",
      "detail": "www.acpjournals.org",
      "url": "https://www.acpjournals.org/doi/10.7326/M19-1795",
      "authors": "www.acpjournals.org",
      "host": "www.acpjournals.org"
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    {
      "number": 23,
      "title": "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/ ...",
      "detail": "www.ahajournals.org",
      "url": "https://www.ahajournals.org/doi/10.1161/CIR.0000000000001251",
      "authors": "www.ahajournals.org",
      "host": "www.ahajournals.org"
    },
    {
      "number": 24,
      "title": "Antithrombotic Therapy in Patients With Chronic Kidney ...",
      "detail": "www.ahajournals.org",
      "url": "https://www.ahajournals.org/doi/10.1161/circulationaha.111.084996",
      "authors": "www.ahajournals.org",
      "host": "www.ahajournals.org"
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  ],
  "editorialNote": "Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.",
  "citations": [
    {
      "number": 1,
      "title": "FDA 1 HIGHLIGHTS OF PRESCRIBING INFORMATION",
      "detail": "www.accessdata.fda.gov",
      "url": "https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/022307s007lbl.pdf",
      "authors": "www.accessdata.fda.gov",
      "host": "www.accessdata.fda.gov",
      "snippet": "Use in Specific Populations (8.5), Clinical Pharmacology (12.3), and Clinical Trials (14)]. • CABG or other surgical procedure [see Warnings and Precautions (5.2)]. • Body weight <60 kg. Consider a lower (5 mg) maintenance dose [see Dosage and Administration (2), Adverse Reactions (6.1), Use in Spec",
      "score": 0.5689194
    },
    {
      "number": 2,
      "title": "[PDF] 4215606 This label may not be the latest approved by FDA. For ...",
      "detail": "www.accessdata.fda.gov",
      "url": "https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/021162s040lbl.pdf",
      "authors": "www.accessdata.fda.gov",
      "host": "www.accessdata.fda.gov",
      "snippet": "increased risk of renal impairment (7.3) • Dual blockade of renin-angiotensin system: Increased risk of renal impairment, hypotension, and hyperkalemia (7.4) • Antidiabetic drugs: Dosage adjustment may be required (7.6) • Cholestyramine and colestipol: Reduced absorption of thiazides (7.7) ---------",
      "score": 0.4199102
    },
    {
      "number": 3,
      "title": "This label may not be the latest approved by FDA. For current ...",
      "detail": "www.accessdata.fda.gov",
      "url": "https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/021162s045lbl.pdf",
      "authors": "www.accessdata.fda.gov",
      "host": "www.accessdata.fda.gov",
      "snippet": "increased risk of renal impairment (7.3) • Dual blockade of renin-angiotensin system: Increased risk of renal impairment, hypotension, and hyperkalemia (7.4) • Antidiabetic drugs: Dosage adjustment may be required (7.6) • Cholestyramine and colestipol: Reduced absorption of thiazides (7.7) ---------",
      "score": 0.4023222
    },
    {
      "number": 4,
      "title": "Prescribing Information (PI) Potpourri",
      "detail": "www.fda.gov",
      "url": "https://www.fda.gov/media/97736/download",
      "authors": "www.fda.gov",
      "host": "www.fda.gov",
      "snippet": "All of the following are discussed in the Dosage and Administration section except: a) Dosing recommendation based on clinical pharmacologic effect (e.g., food effect) b) PK results in patients with hepatic impairment that provide the rationale for a recommended dosage adjustment c) Dosage modificat",
      "score": 0.39089483
    },
    {
      "number": 5,
      "title": "[PDF] 4099012 This label may not be the latest approved by FDA. For ...",
      "detail": "www.accessdata.fda.gov",
      "url": "https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/202107s007lbl.pdf",
      "authors": "www.accessdata.fda.gov",
      "host": "www.accessdata.fda.gov",
      "snippet": "with KORLYM (7.6). -----------------------USE IN SPECIFIC POPULATIONS-----------------------­ • Nursing mothers: Discontinue drug or discontinue nursing (8.3). See 17 for PATIENT COUNSELING INFORMATION and Medication Guide. Revised: 05/2017 Reference ID: 4099012 1 This label may not be the latest ap",
      "score": 0.3493335
    },
    {
      "number": 6,
      "title": "Prescribing Information Resources | FDA",
      "detail": "www.fda.gov",
      "url": "http://www.fda.gov/drugs/fdas-labeling-resources-human-prescription-drugs/prescribing-information-resources",
      "authors": "www.fda.gov",
      "host": "www.fda.gov",
      "snippet": "## 8.1 Pregnancy, 8.2 Lactation, and 8.3 Females and Males Reproductive Potential\n\n### PLLR Rule and Guidance\n\n### PLLR Implementation Schedule, Presentations, and Related Guidance\n\n## 8.4 Pediatric Use\n\n### Pediatric Labeling Rule and Guidance\n\n### Related Guidance\n\n### Presentations and Additional",
      "score": 0.25384757
    },
    {
      "number": 7,
      "title": "Assessment of upper gastrointestinal bleeding - Differential diagnosis of symptoms | BMJ Best Practice",
      "detail": "bestpractice.bmj.com",
      "url": "https://bestpractice.bmj.com/topics/en-gb/456",
      "authors": "bestpractice.bmj.com",
      "host": "bestpractice.bmj.com",
      "snippet": "Laine L, Barkun AN, Saltzman JR, et al. ACG clinical guideline: upper gastrointestinal and ulcer bleeding. Am J Gastroenterol. 2021 May 1;116(5):899-917.Full textAbstract\n\nAmerican College of Radiology. ACR appropriateness criteria®: nonvariceal upper gastrointestinal bleeding. 2024 [internet public",
      "score": 0.48850358
    },
    {
      "number": 8,
      "title": "Diagnosis and management of acute lower gastrointestinal ...",
      "detail": "gut.bmj.com",
      "url": "https://gut.bmj.com/content/68/5/776",
      "authors": "gut.bmj.com",
      "host": "gut.bmj.com",
      "snippet": "## Acknowledgments\n\nWe thank our colleague Carolyn Doree (NHS Blood and Transplant) for designing the literature review search strategy.\n\n## References\n\n## Footnotes\n\nContributors Working subgroups with specific areas of expertise were formed to critically appraise the literature supporting the foll",
      "score": 0.2808584
    },
    {
      "number": 9,
      "title": "Update on the management of upper gastrointestinal ...",
      "detail": "bmjmedicine.bmj.com",
      "url": "https://bmjmedicine.bmj.com/content/1/1/e000202",
      "authors": "bmjmedicine.bmj.com",
      "host": "bmjmedicine.bmj.com",
      "snippet": "Gastric variceal bleeding is less common, but associated with poorer outcomes than oesophageal variceal bleeding.92 The recommended treatment modality advocated by guidelines is dependent on the anatomical location and relationship with any oesophageal varices. The Sarin classification is a useful t",
      "score": 0.26259047
    },
    {
      "number": 10,
      "title": "Evaluation of lower gastrointestinal bleeding - Differential diagnosis of symptoms | BMJ Best Practice US",
      "detail": "bestpractice.bmj.com",
      "url": "https://bestpractice.bmj.com/topics/en-us/457",
      "authors": "bestpractice.bmj.com",
      "host": "bestpractice.bmj.com",
      "snippet": "In developed countries, common causes of acute lower GI bleeding resulting in significant blood loss include colonic diverticular disease and angiodysplasia. Patients with severe bleeding or significant comorbid states require rapid identification and aggressive resuscitation. Hemodynamically insign",
      "score": 0.22950105
    },
    {
      "number": 11,
      "title": "Acute upper gastrointestinal bleeding: state of the art review",
      "detail": "fg.bmj.com",
      "url": "https://fg.bmj.com/content/early/2025/10/22/flgastro-2025-103282.abstract",
      "authors": "fg.bmj.com",
      "host": "fg.bmj.com",
      "snippet": "by ZU Rahman · 2025 · Cited by 3 — Acute upper gastrointestinal bleeding (AUGIB) remains a frequent and life-threatening emergency with mortality rates approaching 9% despite",
      "score": 0.20424701
    },
    {
      "number": 12,
      "title": "What counts as patient-important upper gastrointestinal ...",
      "detail": "bmjopen.bmj.com",
      "url": "https://bmjopen.bmj.com/content/13/5/e070966",
      "authors": "bmjopen.bmj.com",
      "host": "bmjopen.bmj.com",
      "snippet": "by DJ Cook · 2023 · Cited by 15 — upper gastrointestinal bleeding is conventionally defined as bleeding accompanied by haemodynamic changes, requiring red blood cell transfusions or other",
      "score": 0.15988557
    },
    {
      "number": 13,
      "title": "Timing of Endoscopy for Acute Upper Gastrointestinal ...",
      "detail": "www.nejm.org",
      "url": "https://www.nejm.org/doi/full/10.1056/NEJMoa1912484",
      "authors": "www.nejm.org",
      "host": "www.nejm.org",
      "snippet": "by JYW Lau · 2020 · Cited by 489 — It is recommended that patients with acute upper gastrointestinal bleeding undergo endoscopy within 24 hours after gastroenterologic ...Read more",
      "score": 0.085411474
    },
    {
      "number": 14,
      "title": "A Comparison of Omeprazole and Placebo for Bleeding ...",
      "detail": "www.nejm.org",
      "url": "https://www.nejm.org/doi/full/10.1056/NEJM199704103361503",
      "authors": "www.nejm.org",
      "host": "www.nejm.org",
      "snippet": "by MS Khuroo · 1997 · Cited by 513 — Bleeding in the upper gastrointestinal tract is an important cause of hospital admission and death, with an overall incidence of approximately",
      "score": 0.06939668
    },
    {
      "number": 15,
      "title": "Urgent Colonoscopy for the Diagnosis and Treatment ...",
      "detail": "www.nejm.org",
      "url": "https://www.nejm.org/doi/full/10.1056/NEJM200001133420202",
      "authors": "www.nejm.org",
      "host": "www.nejm.org",
      "snippet": "by DM Jensen · 2000 · Cited by 962 — Although endoscopy is often used to diagnose and treat acute upper gastrointestinal bleeding, its role in the management of diverticulosis",
      "score": 0.061384764
    },
    {
      "number": 16,
      "title": "Gaps in acute upper GI bleed (AUGIB) endoscopy training",
      "detail": "fg.bmj.com",
      "url": "https://fg.bmj.com/content/16/2/108",
      "authors": "fg.bmj.com",
      "host": "fg.bmj.com",
      "snippet": "by GB Nigam · 2025 · Cited by 8 — P306 Acute upper GI bleed endoscopic training in the UK: a survey on barriers, experiences, improvement proposals among trainers and trainees. Anna Marfin",
      "score": 0.034844812
    },
    {
      "number": 17,
      "title": "Acute upper gastrointestinal bleeding in the UK: 2022 audit ...",
      "detail": "gut.bmj.com",
      "url": "https://gut.bmj.com/content/75/4/760",
      "authors": "gut.bmj.com",
      "host": "gut.bmj.com",
      "snippet": "by GB Nigam · 2026 · Cited by 11 — At a threshold of 80 g/L, mortality was estimated at 15.5% and 12.3% for inappropriate and appropriate transfusions, respectively (p=0.24) (table 4). After",
      "score": 0.491725
    },
    {
      "number": 18,
      "title": "Transfusion for Acute Upper Gastrointestinal Bleeding",
      "detail": "www.nejm.org",
      "url": "https://www.nejm.org/doi/abs/10.1056/NEJMc1301256",
      "authors": "www.nejm.org",
      "host": "www.nejm.org",
      "snippet": "(Jan. 3 issue)1 conclude that a low hemoglobin threshold for initiating transfusion (hemoglobin level, <7 g per deciliter) improves outcomes in",
      "score": 0.38894346
    },
    {
      "number": 19,
      "title": "ABC score: a new risk score that accurately predicts mortality in acute upper and lower gastrointestinal bleeding: an international multicentre study | Gut",
      "detail": "gut.bmj.com",
      "url": "https://gut.bmj.com/content/70/4/707.full.pdf",
      "authors": "gut.bmj.com",
      "host": "gut.bmj.com",
      "snippet": "Participants and results We included 3012 UGIB patients in the development cohort, and 4019 UGIB and 2336 LGIB patients in the validation cohorts. Age, Blood tests and Comorbidities (ABC) score was closer associated with mortality in UGIB and LGIB (AUROCs: 0.81–84) than existing scores (AUROCs: 0.65",
      "score": 0.3562904
    },
    {
      "number": 20,
      "title": "New Prognostic Risk Score for Gastrointestinal Bleeding | NEJM Clinician",
      "detail": "clinician.nejm.org",
      "url": "https://clinician.nejm.org/new-prognostic-risk-score-gastrointestinal-bleeding-nejm-jw.NA52271",
      "authors": "clinician.nejm.org",
      "host": "clinician.nejm.org",
      "snippet": "Current guidelines recommend using prognostic risk scores in the management of upper gastrointestinal bleeding (UGIB) and lower GI bleeding (LGIB). However, clinicians do not routinely use them as an adjunct to clinical judgment, partly because of the perceived difficulty of the calculations and the",
      "score": 0.30544916
    },
    {
      "number": 21,
      "title": "Dose adjustment in renal impairment: Response from Drug Prescribing in Renal Failure | The BMJ",
      "detail": "www.bmj.com",
      "url": "https://www.bmj.com/content/331/7511/293.2",
      "authors": "www.bmj.com",
      "host": "www.bmj.com",
      "snippet": "EDITOR—Vidal et al should be congratulated on the first scholarly, systematic review of secondary sources of prescribing information for patients with impaired renal function (p 263).1 That they found inconsistent and conflicting recommendations across multiple sources is not surprising. Their work ",
      "score": 0.29220682
    },
    {
      "number": 22,
      "title": "Management of Nonvariceal Upper Gastrointestinal Bleeding",
      "detail": "www.acpjournals.org",
      "url": "https://www.acpjournals.org/doi/10.7326/M19-1795",
      "authors": "www.acpjournals.org",
      "host": "www.acpjournals.org",
      "snippet": "by AN Barkun · 2019 · Cited by 792 — The 2010 UGIB guidelines recommended early endoscopy (within 24 hours of presentation) for most patients with acute UGIB (4). This ...Read more",
      "score": 0.46949652
    },
    {
      "number": 23,
      "title": "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/ ...",
      "detail": "www.ahajournals.org",
      "url": "https://www.ahajournals.org/doi/10.1161/CIR.0000000000001251",
      "authors": "www.ahajournals.org",
      "host": "www.ahajournals.org",
      "snippet": "by HL Gornik · 2024 · Cited by 1002 — The term guideline-directed management and therapy (GDMT) encompasses clinical evaluation, diagnostic testing, and both pharmacological and",
      "score": 0.07303915
    },
    {
      "number": 24,
      "title": "Antithrombotic Therapy in Patients With Chronic Kidney ...",
      "detail": "www.ahajournals.org",
      "url": "https://www.ahajournals.org/doi/10.1161/circulationaha.111.084996",
      "authors": "www.ahajournals.org",
      "host": "www.ahajournals.org",
      "snippet": "by D Capodanno · 2012 · Cited by 197 — For patients with stage 4 CKD, dose adjustment to 75 mg twice daily is recommended by the Food and Drug Administration (FDA) high bleeding",
      "score": 0.53196377
    }
  ],
  "publishedAt": "2026-08-20T23:55:36.291484Z",
  "updatedAt": "2026-08-20T23:55:36.291484Z",
  "readingMinutes": 7,
  "slug": "upper-gastrointestinal-bleeding"
}