Not normally difficult to spot, but look for it in unexplained anaemia, or collapse.

Questions

• Is it VARICEAL? Mortality 35%, so is an emergency whatever the GBS is.
• Non-Variceal what’s the GBS? will help guide treatment

Anyone being admitted should be brought to HRI

Emergency Endoscopy is arranged by Med Reg

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Glasgow-Blatchford Score (GBS)

Urea level		Haemoglobin [Male]		Haemoglobin [Female]		Systolic BP		Other
≥6·5 <8·0	2	≥120 <130	1	≥100 <120	1	100–109	1	Pulse ≥100 bpm	1
≥8·0 <10·0	3	≥100 <120	3	<100	6	90–99	2	Melaena	1
≥10·0 <25·0	4	<100	6			<90	3	Syncope	2
≥25	6							Hepatic disease	2
								Cardiac failure	2

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ESGE guidance – learning points for ED

1. Resuscitation before endoscopy

ESGE makes a strong recommendation for immediate haemodynamic assessment and prompt intravascular volume replacement in unstable patients, initially using crystalloid.

This does not mean indiscriminate aggressive fluid loading. The aim is effective resuscitation, haemorrhage control and restoration of perfusion, with blood products as indicated.

What is the evidence on very early endoscopy?

Timing	ESGE position
≤6 hours	Not routinely recommended
≤12 hours	Not routinely recommended
Within 24 hours	Recommended after haemodynamic resuscitation
Persistent instability despite resuscitation	Consider emergency endoscopy

The guideline reviews evidence associating very early endoscopy with higher mortality in some observational studies. However, confounding by severity and incomplete resuscitation may explain this association.

Importantly, a randomised trial comparing endoscopy within 6 hours against 6–24 hours found no improvement in 30-day mortality, rebleeding, transfusion requirements or hospital length of stay.

2. Prokinetics before endoscopy

The purpose is to empty blood and clots from the stomach, improving visualisation and potentially reducing repeat procedures. (Only shortly before endoscopy and would be directed by endoscopist)

Drug	Recommendation	Evidence
IV erythromycin	Preferred in selected patients with severe or ongoing bleeding	Strong recommendation, high-quality evidence
IV metoclopramide	Alternative when erythromycin is unavailable	Conditional recommendation, low-quality evidence

The guideline’s evidence review includes erythromycin 250 mg IV, typically 30–60 minutes before endoscopy, and metoclopramide 10 mg IV, administered 10–30 minutes before endoscopy in one major trial.

The pooled metoclopramide evidence showed improved endoscopic visualisation (mean difference 0.37, 95% CI 0.12–0.62; p=0.004), but no significant improvement in transfusion requirements or length of stay. The reduction in repeat endoscopy was not statistically significant (RR 0.60, 95% CI 0.32–1.11).

3. Antiplatelets and anticoagulants

The guideline also reinforces several practical decisions:

• Aspirin for secondary prevention: generally continue; if interrupted, restart promptly, preferably within 3–5 days.
• Aspirin for primary prevention: temporarily interrupt and reassess the indication.
• Dual antiplatelet therapy: generally continue aspirin, temporarily withhold the second agent and seek cardiology advice.
• Warfarin and DOACs: withhold during acute bleeding; consider reversal for severe bleeding or instability as appropriate.
• Platelet transfusion: not routinely indicated solely because the patient is taking antiplatelet medication.

These antithrombotic recommendations are largely carried forward from 2021 rather than newly reassessed in 2026. esge.com

4. Consideration of PPI

There is no convincing evidence that routine IV PPI administration before endoscopy in suspected upper gastrointestinal bleeding reduces mortality, rebleeding or the need for surgery. Although it may reduce the requirement for endoscopic haemostatic intervention, this has not translated into demonstrated improvements in major clinical outcomes.

The ESGE 2026 guideline therefore makes only a conditional recommendation to consider pre-endoscopy IV PPI therapy, supported by low-quality evidence. Routine IV PPI administration in the ED is not required; treatment may be considered selectively and must not delay definitive endoscopic assessment.

High-dose PPI treatment following endoscopic haemostasis of high-risk peptic ulcers remains strongly recommended.

The guideline cites a Cochrane meta-analysis of six randomised trials examining PPI treatment before endoscopy.

Outcome	Odds ratio (95% CI)	Interpretation
Mortality	1.14 (0.76–1.70)	No demonstrated benefit
Rebleeding	0.81 (0.62–1.06)	Possible benefit, not statistically significant
Surgery	0.91 (0.65–1.26)	No demonstrated benefit
Endoscopic haemostasis required	0.68 (0.50–0.93)	Statistically significant reduction
High-risk endoscopic stigmata	0.80 (0.52–1.21)	No clear reduction

A further observational study involving 2,566 patients found no significant difference in high-risk endoscopic appearances between patients receiving pre-endoscopy PPIs and those not receiving them (51.8% versus 53.4%; p=0.58)