Upper GI Bleeding: Ulcers, Varices, and Stabilization Explained
Stuart Moore 18 December 2025 11

When someone vomits blood or passes black, tarry stools, it’s not just a bad stomach bug-it’s a medical emergency. Upper gastrointestinal (GI) bleeding can happen to anyone, but it’s most common in older adults and those with liver disease or long-term use of NSAIDs. The truth is, many people ignore the warning signs until they collapse. And by then, it’s too late for simple fixes. This isn’t rare. In the U.S., about 100 people out of every 100,000 experience an upper GI bleed each year. That’s 300,000 hospitalizations annually, costing billions. The good news? With the right knowledge and fast action, most cases can be stopped before they turn fatal.

What Exactly Is Upper GI Bleeding?

Upper GI bleeding means blood is coming from somewhere in the upper part of your digestive tract: the esophagus, stomach, or the first part of the small intestine (duodenum). It doesn’t mean a cut or a wound-it’s usually caused by something breaking down inside you. The most common culprits? Peptic ulcers and esophageal varices.

Peptic ulcers, which are open sores in the stomach or duodenum, cause about half of all upper GI bleeds. These often form because of Helicobacter pylori infection or long-term use of painkillers like ibuprofen or aspirin. Esophageal varices, on the other hand, are swollen veins in the esophagus, usually from advanced liver disease. When pressure builds in the portal vein system, these veins burst. They’re dangerous because they don’t just leak-they gush. About 20% of people with variceal bleeding die within six weeks if not treated immediately.

Other causes include erosive gastritis (stomach lining worn away), Mallory-Weiss tears (rips from violent vomiting), and even stomach cancer. SSRIs, commonly prescribed for depression, double the risk of bleeding. And yes, even something as simple as a hiatal hernia can cause bleeding in about 5% of cases.

How Do You Know You’re Bleeding?

Some signs are obvious. Vomiting bright red blood? That’s hematemesis-clear warning. But if the blood has been sitting in your stomach, it turns dark and gritty, like coffee grounds. That’s still bleeding. Black, sticky stools? That’s melena-digested blood. It smells awful, like tar. Some people mistake it for iron supplements or food dyes. Don’t. If you’re dizzy, your heart is racing, or you feel faint, your body is telling you you’re losing blood.

Low blood pressure (below 90 mmHg) and a heart rate over 100 beats per minute are classic signs of shock from blood loss. In older adults, these symptoms can be subtle. One patient thought she was just tired-until her hemoglobin dropped to 5.8 g/dL. Normal is 12-16. At 5.8, you’re on the edge of organ failure.

Even if you don’t vomit or pass black stool, bleeding can still be happening. That’s why doctors rely on more than symptoms. They check your blood. A high BUN-to-creatinine ratio (above 30:1) is a strong indicator of upper GI bleeding, with 68.8% accuracy. It’s not perfect, but it’s one of the first clues.

How Doctors Assess Your Risk

Not every case needs the same level of care. That’s where the Glasgow-Blatchford score comes in. Developed in 2000 and updated in 2019, it’s a simple tool that uses numbers, not guesses. It looks at your hemoglobin level, blood pressure, heart rate, whether you have melena, if you’ve fainted, and if you have liver or heart disease. A score of 2 or higher means you need hospital care. A score of 0? You might be safe to go home.

Studies show this score identifies 15% of patients who don’t need to be admitted at all. That’s huge. It prevents unnecessary hospital stays and frees up resources for those who really need them. But here’s the catch: too many doctors skip the score and just start PPIs (acid-reducing drugs) on everyone. That’s wrong. One study found that 30% of low-risk patients got unnecessary treatment because no one checked the score.

Doctor performing endoscopy on a patient, with a glowing endoscope revealing a skeletal ulcer and floating medical tools.

What Happens in the ER?

Time matters. The faster you get help, the better your odds. The goal? Stabilize you first, then find the source. That means IV fluids, oxygen, and sometimes a blood transfusion. If your hemoglobin is below 7 g/dL-or you’re dizzy, short of breath, or your heart is struggling-you’ll get packed red blood cells. Each unit raises your hemoglobin by about 1 g/dL. But don’t aim too high. Target 7-9 g/dL. Giving too much blood can actually hurt you.

Then comes the most important step: endoscopy. Not tomorrow. Not in 24 hours. Within 12 hours if you’re high risk. Studies show doing it within 12 hours cuts death rates by 25% compared to waiting longer. That’s not a suggestion-it’s standard care. The endoscope lets the doctor see exactly where the bleed is. And they use the Forrest classification to judge how bad it is.

Class Ia? Blood spurting out. 90% chance of rebleeding without action. Class Ib? Oozing. 50% risk. Class IIa? A visible blood vessel. Also 50% risk. If you have any of these, you need immediate treatment-no waiting.

Treatment: Stopping the Bleed

For ulcers and non-variceal bleeding, the first step is high-dose proton pump inhibitors (PPIs). You get an 80mg IV push, then a continuous drip of 8mg per hour. This isn’t just to reduce pain-it’s to stop the bleeding. The COBALT trial showed this cuts rebleeding from 22.6% to 11.6%. That’s more than half the risk gone.

But PPIs alone aren’t enough. Endoscopic treatment is key. Doctors use epinephrine injections to shrink blood vessels, then seal the area with heat (thermal coagulation) or metal clips (hemoclips). Together, these methods stop bleeding in 90-95% of cases. For stubborn bleeds, a new tool called Hemospray (an inorganic powder) has been approved by the FDA. It forms a barrier over the wound. In trials, it worked in 92% of cases where other methods failed.

For varices, it’s a different game. You get vasoactive drugs-terlipressin or octreotide-right away. These drugs squeeze the veins to stop the flow. You also get antibiotics (usually ceftriaxone) because infection is a major killer in these patients. Then comes endoscopic band ligation. That’s when they put tiny rubber bands around the swollen veins. It’s more effective than injecting chemicals (sclerotherapy), cutting rebleeding from 60% down to 25%.

Family altar honoring GI bleed survivors with medical offerings, giant healed skeleton holding 'Follow-Up' sign.

What Happens After You’re Stable?

Surviving the bleed is only half the battle. The other half is preventing it from coming back. Most people don’t realize how much lifestyle matters. A 2022 study found 42% of patients changed their diet after discharge-cutting out coffee, alcohol, spicy food. Thirty-one percent stopped NSAIDs cold turkey, without talking to a doctor. That’s dangerous. You need guidance.

If you had an ulcer caused by H. pylori, you’ll need antibiotics. If it’s from NSAIDs, you’ll need alternatives. If you have liver disease and varices, you might need a procedure called TIPS (transjugular intrahepatic portosystemic shunt) to reduce pressure. And you’ll need follow-up endoscopies to check if the varices are still there.

But here’s the thing: most patients don’t get proper follow-up. The Upper GI Bleed Bundle from Massachusetts General Hospital fixes that. It’s a checklist: assess within 30 minutes, use the Glasgow score, give PPIs within an hour, do endoscopy within 12 hours, and schedule a follow-up within 72 hours. Hospitals using this bundle cut their 30-day death rate from 8.7% to 5.3%.

The Future: AI and Personalized Care

The field is changing fast. In 2024, the American College of Gastroenterology will start recommending AI-assisted endoscopy. These systems use machine learning to spot bleeding spots humans miss. In trials, they caught 94.7% of bleeds-compared to 78.3% for doctors. That’s a big jump. But there’s a problem: most AI tools were trained on data from white patients. They’re 15% less accurate in Black and Hispanic populations. That’s not just a technical flaw-it’s a health equity issue.

The NIH is running a massive study called UGIB-360, tracking 10,000 people to build personalized risk models. They’re looking at your genes, your gut bacteria, your medications, your history. The goal? Predict who’s going to bleed before it happens. Results are expected in late 2025. If it works, we’ll move from emergency response to prevention.

What You Need to Do Now

If you’ve had an upper GI bleed:

  • Don’t ignore black stools or coffee-ground vomit. Call your doctor or go to the ER.
  • Stop NSAIDs unless your doctor says it’s safe.
  • Ask if you need testing for H. pylori or liver disease.
  • Ask for the Glasgow-Blatchford score. Don’t assume you need to be hospitalized.
  • Follow up with a gastroenterologist. Don’t wait for symptoms to return.

If you’re at risk-older, on blood thinners, have liver disease, or take SSRIs-talk to your doctor about prevention. There are safe pain relievers. There are ways to monitor your liver. There are steps you can take now to avoid the ER.

Upper GI bleeding isn’t something you recover from and forget. It’s a warning. And if you listen, you can live a long time after it.

What does coffee-ground vomit mean?

Coffee-ground vomit means blood has been in your stomach long enough to be partially digested by stomach acid. It’s not fresh bleeding, but it’s still a sign of an active upper GI bleed. It often comes from ulcers or gastritis and requires medical evaluation.

Can you have an upper GI bleed without vomiting blood?

Yes. Many people only notice black, tarry stools (melena) or feel dizzy and weak. Some don’t have any visible signs until they collapse. That’s why doctors rely on blood tests and risk scores-not just symptoms.

How long does it take to recover from an upper GI bleed?

Recovery depends on the cause and severity. Most people stay in the hospital for 3-7 days. Full recovery can take weeks, especially if you had a major bleed or liver disease. You’ll need follow-up endoscopies and lifestyle changes to prevent recurrence.

Are ulcers the only cause of upper GI bleeding?

No. While ulcers cause 40-50% of cases, other major causes include esophageal varices (10-20%), erosive gastritis (15-20%), Mallory-Weiss tears (5-10%), and even cancers. Medications like SSRIs and NSAIDs also significantly increase risk.

Is upper GI bleeding more common in older adults?

Yes. Rates jump from 50 per 100,000 in people under 50 to 300 per 100,000 in those over 80. This is due to more chronic diseases, higher use of blood thinners and NSAIDs, and increased rates of liver disease and cancer in older populations.

Can I prevent upper GI bleeding?

You can reduce your risk. Avoid long-term NSAID use, treat H. pylori if you have it, limit alcohol, manage liver disease, and talk to your doctor about safer pain relief options. If you’re on SSRIs or blood thinners, ask about your bleeding risk and whether you need a stomach-protecting medication.