Nonvariceal upper GI bleeding worked as a fixed sequence: perfusion first, diagnosis second, endoscopy third. The first hour moves mortality more than the scope does. Covers resuscitation, transfusion thresholds, pre-endoscopy pharmacology, risk scores, anticoagulant reversal, Forrest-directed endoscopic therapy, and post-hemostasis medical management. Topics covered Resuscitation and airway in massive UGIB Restrictive transfusion threshold Pre-endoscopy PPI and erythromycin Glasgow-Blatchford risk stratification Timing of endoscopy within 24 hours Anticoagulant and antiplatelet management Forrest classification and dual therapy H. pylori eradication and secondary prevention Key decisions Transfuse red cells at hemoglobin 7 in most patients; aim 8 to 10 only in acute coronary syndrome; the stable cirrhotic variceal bleeder does worse with a liberal target. High-dose IV PPI targets intragastric pH above 6 to stop clot lysis; give 72 hours after hemostasis of a high-risk lesion, then oral taper. Glasgow-Blatchford 0 or 1 identifies the very-low-risk patient for outpatient endoscopy; Rockall needs the scope and AIMS65 predicts ICU need, not the go-home patient. Non-variceal endoscopy within 24 hours with no benefit before 6; tranexamic acid is not used in acute UGIB. Reverse warfarin with 4-factor PCC plus IV vitamin K, dabigatran with idarucizumab, Xa inhibitors with andexanet alfa reserved for life-threatening bleeding; resume early because late risk is thrombotic. High-risk Forrest stigmata (spurting, oozing, non-bleeding visible vessel) get dual therapy: epinephrine plus a thermal method or clip; epinephrine alone is inadequate; over-the-scope clip rescues the recurrent bleeder. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected]. (00:00) - The fixed sequence: perfusion, diagnosis, endoscopy (00:39) - Resuscitation and airway (01:08) - Restrictive transfusion threshold (02:09) - Pre-endoscopy acid suppression and erythromycin (03:35) - Risk stratification and disposition (04:21) - Timing of endoscopy (05:01) - Anticoagulant and antiplatelet management (07:58) - Forrest classification and endoscopic therapy

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