When you vomit something that looks like coffee grounds, or pass black, tarry stools, it’s not just a bad stomach bug. It’s a medical emergency. Upper GI bleeding-bleeding from the esophagus, stomach, or first part of the small intestine-is more common than most people realize. About 100 out of every 100,000 adults in the U.S. experience it each year. And while some cases are mild, others can kill within hours if not treated fast. The two biggest culprits? Peptic ulcers and esophageal varices. Both need urgent care, but they’re handled very differently.
What Causes Upper GI Bleeding?
- Peptic ulcers (40-50% of cases): These are open sores in the stomach or duodenum. Most are caused by H. pylori bacteria or long-term use of NSAIDs like ibuprofen or aspirin. Duodenal ulcers bleed more often than gastric ones.
- Esophageal varices (10-20%): These are swollen, fragile veins in the esophagus, usually from advanced liver disease and portal hypertension. They can rupture without warning. Once they bleed, the death rate within six weeks is about 20%.
- Erosive gastritis (15-20%): Inflammation that wears away the stomach lining, often from alcohol, stress, or medications.
- Mallory-Weiss tears (5-10%): A tear in the esophagus from violent vomiting or retching.
- SSRIs: Antidepressants like sertraline or fluoxetine double the risk of upper GI bleeding, according to a 2022 JAMA study of half a million patients.
Many people don’t realize their bleeding is serious. They think black stools mean they’re taking iron supplements. One Reddit user, u/StomachSOS, waited two weeks after his doctor dismissed his symptoms-until he collapsed. His hemoglobin was 5.8 g/dL. Normal is 13-17 for men. That’s life-threatening.
How Do You Know It’s Bleeding?
- Hematemesis: Vomiting bright red blood means fresh bleeding. Coffee-ground vomit means the blood has been sitting in the stomach-still serious, but slightly slower.
- Melena: Black, sticky, foul-smelling stools. This means blood has passed through the whole digestive tract. It’s a classic sign.
- Hematochezia: Bright red or maroon stools. This usually means lower GI bleeding, but in massive upper GI bleeds, blood can rush through too fast to darken.
- Physical signs: Heart rate over 100 bpm, low blood pressure (under 90 systolic), dizziness, fainting, pale skin, cold sweats. These mean your body is going into shock.
If you have even one of these symptoms, especially with a history of liver disease, ulcers, or NSAID use, go to the ER. Don’t wait. Don’t call your GP. Go.
The Glasgow-Blatchford Score: Your First Triage Tool
Not every person with upper GI bleeding needs a hospital bed. The Glasgow-Blatchford score (GBS), developed in 2000 and updated in 2019, helps doctors decide who’s at risk. It uses six simple, objective numbers:
- Hemoglobin level (below 12.9 for men, 11.9 for women)
- Systolic blood pressure (under 100 mmHg)
- Pulse rate (over 100 bpm)
- Presence of melena
- History of syncope (fainting)
- History of liver or heart disease
A score of 2 or higher means you need hospital care. A score of 0? You might be able to go home safely. A 2023 study in Gastroenterology showed this score correctly identified 85% of patients who needed intervention. Dr. Robert Logan from Harvard says it’s “revolutionized triage”-it keeps low-risk patients out of the hospital and focuses resources on those who need it most.
What Happens in the ER?
When you arrive, the team doesn’t waste time. They follow a strict sequence:
- Stabilize first: IV fluids, oxygen, monitoring heart and blood pressure. If you’re dizzy or pale, they’ll start blood transfusions right away.
- Lab tests: CBC (to check hemoglobin), INR (to check clotting), and BUN-to-creatinine ratio. A ratio over 30:1 has a 68.8% chance of confirming upper GI bleeding.
- Start PPIs: If you’re high-risk, they’ll give you an 80mg IV bolus of a proton pump inhibitor like omeprazole, then an 8mg/hour drip. The COBALT trial showed this cuts rebleeding from 22.6% to 11.6%.
- Endoscopy within 12-24 hours: This isn’t optional. The 2022 American Gastroenterological Association guidelines say doing it within 12 hours cuts death risk by 25%.
Endoscopy is where the real diagnosis happens. Doctors look for the source using the Forrest classification:
- Class Ia: Spurting blood. 90% chance of rebleeding without treatment.
- Class Ib: Oozing. 50% rebleeding risk.
- Class IIa: Visible vessel. Also 50% risk.
- Class IIb: Adherent clot. Lower risk, but still needs treatment.
- Class III: Clean base. No active bleeding. Lowest risk.
That’s why you can’t just take antacids and hope it goes away. If you have a visible vessel, you need endoscopic therapy-clips, heat, or injection-right then.
How Are Ulcers Treated?
For non-variceal bleeding (like ulcers), treatment is straightforward:
- Endoscopic therapy: Epinephrine injection to stop blood flow, then hemoclips or thermal probes to seal the vessel. Success rate: 90-95%.
- PPI drip: Continue the IV infusion for 72 hours, then switch to oral pills.
- Test for H. pylori: If positive, you’ll get antibiotics (usually amoxicillin + clarithromycin + PPI) for 14 days.
- Stop NSAIDs: If you’re taking ibuprofen, naproxen, or aspirin, you stop them. Your doctor will suggest alternatives like acetaminophen.
One patient from Michigan, tracked in a 2022 study, said he stopped taking ibuprofen for his back pain after his bleed-then realized he’d been taking it daily for 10 years. He didn’t know it could cause this.
How Are Varices Treated?
Variceal bleeding is a different beast. It’s not about acid or bacteria-it’s about pressure. The veins are stretched thin by liver scarring. Treatment is aggressive:
- Vasoactive drugs: Terlipressin or octreotide given IV immediately. These shrink the veins. Used with antibiotics (ceftriaxone), they cut death risk by 25%.
- Band ligation: During endoscopy, doctors place tiny rubber bands around the varices. This cuts off blood flow. It’s better than older methods like sclerotherapy, reducing rebleeding from 60% to 25%.
- Transjugular intrahepatic portosystemic shunt (TIPS): For recurrent bleeding, a stent is placed inside the liver to reroute blood flow. It’s a major procedure, but lifesaving for cirrhosis patients.
Patients with varices often need lifelong monitoring. Even after bleeding stops, they’re at high risk for another episode. Many end up on beta-blockers like propranolol to lower pressure in the portal vein.
What About Blood Transfusions?
There’s been a big shift in how we treat low hemoglobin. In the past, doctors rushed to transfuse to normal levels. Now, we aim for 7-9 g/dL. Why? Because giving too much blood can cause fluid overload, especially in patients with liver disease.
Each unit of packed red blood cells raises hemoglobin by about 1 g/dL. If your hemoglobin is 6.5, two units will get you to 8.5-safe and effective. Studies show no benefit to pushing above 9 g/dL unless the patient is actively having chest pain or heart failure.
What’s New in 2025?
Technology is changing how we see and stop bleeding.
- Hemospray: A powder sprayed during endoscopy that sticks to bleeding sites. FDA-approved in 2023, it’s now used for stubborn cases where clips won’t work.
- AI-assisted endoscopy: New systems can spot tiny bleeding spots humans miss. In the 2023 ENDOSCAPE trial, AI found bleeding with 94.7% accuracy-compared to 78.3% for human endoscopists. But there’s a catch: these systems were trained mostly on white patients. Accuracy drops 15% in Black and Hispanic patients. That’s a serious gap.
- UGIB-360 study: Launched in January 2024, this NIH project is tracking 10,000 patients to predict who’ll bleed again. It’s using genetics, gut bacteria, and clinical data to build personalized risk models. Results are due by late 2025.
What Happens After You Leave the Hospital?
Recovery isn’t over when you walk out. A University of Michigan study found 68% of patients felt anxious about another bleed within 30 days. Many changed their habits:
- 42% cut out spicy food, caffeine, and alcohol
- 31% stopped NSAIDs without telling their doctor
- 28% didn’t follow up with a gastroenterologist
That last one is dangerous. If you had an ulcer, you need a repeat endoscopy in 6-8 weeks to make sure it’s healed. If you had varices, you need banding every 2-4 weeks until they’re gone. Skipping follow-up means you’re gambling with your life.
Also, if you’re on SSRIs, talk to your doctor. Don’t quit cold turkey. They can switch you to a safer antidepressant or add protective meds like a PPI.
When Should You Call 911?
Don’t wait. Call emergency services if you have:
- Vomiting bright red blood
- Black, tarry stools with dizziness or fainting
- Heart rate over 110 and feeling weak
- A history of cirrhosis or ulcers and new bleeding symptoms
Time is everything. The faster you get to a hospital with endoscopy capability, the better your chance of survival.
Is upper GI bleeding the same as a stomach ulcer?
No. A stomach ulcer is a sore in the lining of the stomach or duodenum. Upper GI bleeding is when that ulcer (or another problem like varices) starts to bleed. Not all ulcers bleed, but when they do, it becomes an emergency. Ulcers are a common cause of upper GI bleeding, but not the only one.
Can stress cause upper GI bleeding?
Stress doesn’t directly cause ulcers, but it can trigger erosive gastritis or make existing bleeding worse. Severe physical stress-like from major surgery, burns, or ICU stays-can cause stress ulcers. Emotional stress alone is unlikely to be the main cause, but it can lead people to use NSAIDs or alcohol more, which do cause bleeding.
Do I need to avoid alcohol forever after an upper GI bleed?
Yes-if your bleed was related to liver disease or varices, alcohol must be stopped completely. Even if it wasn’t, alcohol irritates the stomach lining and increases bleeding risk. Most gastroenterologists recommend lifelong abstinence after any upper GI bleed, especially if you’re on PPIs or have a history of ulcers.
Can I take ibuprofen again after my ulcer heals?
It’s not recommended. Even after healing, NSAIDs increase your risk of another bleed by 3-5 times. If you need pain relief, use acetaminophen (paracetamol) instead. If you absolutely need an NSAID, your doctor may prescribe a PPI at the same time-but it’s still risky. Ask about non-drug options like physical therapy or nerve blocks.
Is upper GI bleeding more common in older people?
Yes. Rates jump from 50 per 100,000 in people under 50 to over 300 per 100,000 in those over 80. Why? Older adults are more likely to take NSAIDs, have H. pylori infections, have liver disease, and have thinner stomach linings. They’re also more likely to be on blood thinners. Age is one of the strongest risk factors.
