When you vomit something that looks like coffee grounds, or pass black, tarry stools, it’s not just indigestion. It’s a medical emergency. Upper GI bleeding isn’t rare-it happens to about 100 people per 100,000 every year in the U.S., and it can kill if not handled fast. The bleeding comes from the esophagus, stomach, or first part of the small intestine. The two biggest culprits? Peptic ulcers and esophageal varices. And the difference between life and death often comes down to how quickly you get stabilized and diagnosed.
What Does Upper GI Bleeding Look Like?
You don’t need to be bleeding out to know something’s wrong. The signs are specific-and they’re hard to ignore once you’ve seen them.
- Hematemesis: Vomiting blood. Bright red means fresh bleeding. Coffee-ground vomit means the blood has been sitting in the stomach, partially digested.
- Melena: Black, sticky, foul-smelling stools. This is digested blood passing through the gut. It’s not from eating beets or iron pills-it’s a red flag.
- Hematochezia: Maroon or bright red stools. This usually means massive bleeding, where blood moves too fast to darken.
- Physical signs: Dizziness, fainting, rapid heartbeat (over 100 bpm), low blood pressure (below 90 systolic), pale skin. These mean your body is going into shock from blood loss.
One patient in a 2023 Reddit thread described waking up at 3 a.m. coughing up coffee-ground material. By the time he got to the ER, he’d lost three units of blood. He spent eight days in the hospital. That’s not unusual. Delayed care turns manageable bleeding into life-threatening collapse.
Ulcers vs. Varices: The Two Main Causes
Not all upper GI bleeding is the same. The cause changes everything-from treatment to survival odds.
Peptic ulcers (40-50% of cases) are open sores in the stomach or duodenum. Most are caused by H. pylori bacteria or long-term NSAID use (like ibuprofen or naproxen). Duodenal ulcers bleed more often than gastric ones. A bleeding ulcer doesn’t always hurt. Some people have no pain at all-just sudden weakness or black stools.
Esophageal varices (10-20% of cases) are swollen veins in the esophagus, usually from liver disease like cirrhosis. These veins are thin-walled and under high pressure. One small tear can cause massive bleeding. Mortality is high: 20% die within six weeks. Unlike ulcers, varices often bleed without warning. Patients may have no abdominal pain, just sudden vomiting of bright red blood.
Other causes? Erosive gastritis (15-20%), Mallory-Weiss tears (from violent vomiting), esophagitis, and even cancer (2-5%). And yes-SSRIs (common antidepressants) double your risk of bleeding. If you’re on one and notice black stools, don’t wait.
Stabilization: The First 30 Minutes Matter
Before you even get to endoscopy, you need to stabilize. This isn’t optional. It’s the foundation of survival.
Step one: Check vital signs. Heart rate over 100? Systolic BP under 90? That’s shock. Start IV fluids immediately. Oxygen if needed. Position the patient flat, legs elevated.
Step two: Blood tests. Hemoglobin, INR (to check clotting), and BUN-to-creatinine ratio. A ratio above 30:1 has a 69% chance of indicating upper GI bleeding. It’s not perfect, but it’s fast and cheap.
Step three: Don’t wait for endoscopy to give PPIs. For suspected ulcers, give an 80mg IV bolus of pantoprazole or omeprazole, then an 8mg/hour infusion. The COBALT trial showed this cuts rebleeding from 22.6% to 11.6%. That’s half the chance of needing another surgery or transfusion.
Step four: Transfuse only if needed. Target hemoglobin between 7 and 9 g/dL. Giving too much blood can worsen outcomes. One unit of packed red cells raises hemoglobin by about 1 g/dL. Don’t aim for normal-aim for stable.
Step five: For varices, start vasoactive drugs immediately. Terlipressin or octreotide. Add antibiotics-ceftriaxone 1g daily. This combo cuts death by 25%. Don’t delay. Every minute counts.
Diagnosis: Endoscopy Is Non-Negotiable
Lab tests and symptoms point you in the right direction. Only endoscopy confirms it.
All major guidelines agree: Get an esophagogastroduodenoscopy (EGD) within 24 hours. Better yet-within 12 hours. A 2022 study showed that doing it within 12 hours reduces death by 25% compared to waiting longer.
During the procedure, doctors use the Forrest classification to judge bleeding risk:
- Class Ia: Spurting blood. 90% chance of rebleeding without treatment.
- Class Ib: Oozing. 50% 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. Low risk.
For ulcers: Endoscopic therapy means epinephrine injection + either thermal coagulation or hemoclips. Success rate? 90-95%.
For varices: Band ligation is the gold standard. It cuts rebleeding from 60% to 25%. Sclerotherapy? Outdated. Less effective, more complications.
Who Can Go Home? The Glasgow-Blatchford Score
Not every person with GI bleeding needs a hospital bed. That’s where the Glasgow-Blatchford score comes in.
This scoring system uses six simple things:
- Hemoglobin (below 12.9 for men, 11.9 for women)
- Systolic blood pressure (below 100)
- Pulse rate (above 100)
- Melena
- Syncope (fainting)
- History of liver or heart disease
A score of 2 or higher? Hospitalize. A score of 0 or 1? You can probably go home safely. A 2019 study of over 3,000 patients showed this score correctly identifies 15% of patients who don’t need intervention. That saves money, reduces hospital exposure, and avoids unnecessary stress.
But here’s the catch: Don’t rely on PPIs alone to rule out bleeding. A Johns Hopkins doctor found that 30% of low-risk patients get unnecessary PPI treatment because doctors skip endoscopy. That’s dangerous. PPIs mask symptoms-they don’t fix the cause.
What’s New in 2026?
Technology is changing how we treat this.
Hemospray, an inorganic powder sprayed during endoscopy, works like a bandage over bleeding spots. It’s not for everyone-but for tricky cases where clips or bands won’t stick, it’s a game-changer. Studies show it stops bleeding in 92% of tough cases.
AI-assisted endoscopy is coming fast. A 2023 trial showed AI systems spotted bleeding signs 94.7% of the time. Human endoscopists? Only 78.3%. That’s a huge jump. But there’s a problem: AI trained mostly on white patients misses signs in Black and Hispanic patients 15% more often. Validation across diverse populations is still lagging.
And the NIH is running a massive study called UGIB-360, tracking 10,000 people to build personalized risk models using DNA, gut bacteria, and clinical data. Results won’t be out until late 2025-but when they are, we’ll finally know who’s at highest risk before they even bleed.
What Happens After?
Surviving the bleed is only half the battle.
A 2022 study found 68% of patients felt anxious about bleeding again within 30 days. Nearly half changed their diet-cutting caffeine, alcohol, spicy food. One in three stopped NSAIDs without telling their doctor. That’s risky. Stopping cold turkey can cause rebound pain or worsen arthritis. Talk to your provider.
If you had an ulcer: You’ll need H. pylori testing. If positive, antibiotics + PPI for 14 days. If you took NSAIDs, you’ll need to switch to acetaminophen or use a PPI long-term.
If you had varices: You’ll need beta-blockers (like propranolol) to lower pressure in the veins. You’ll need follow-up endoscopies every 1-2 years. And you’ll need to avoid alcohol completely.
Rebleeding? It’s common. And it’s deadly. Each rebleed raises your hospital cost by 65%. The goal isn’t just to stop the first bleed-it’s to prevent the next one.
Bottom Line
Upper GI bleeding is serious. But it’s not mysterious. Know the signs. Act fast. Get endoscopy within 12 hours. Use the Glasgow-Blatchford score to avoid overtreating. Treat ulcers with PPIs and endoscopy. Treat varices with drugs and bands. Don’t guess. Don’t wait. And don’t ignore black stools or coffee-ground vomit. They’re not normal. They’re a scream for help.
The systems that save lives now-rapid assessment, risk scoring, early endoscopy, targeted treatment-are proven. They’re not futuristic. They’re here. And they work-if you use them.
