Acute upper gastrointestinal bleeding: state of the art review

Acute upper gastrointestinal bleeding (AUGIB) remains a frequent and life-threatening emergency with mortality rates approaching 9% despite therapeutic advances. This state-of-the-art narrative review synthesises recent evidence (2020–2025) across the continuum of AUGIB care, covering primary prevention, pre-endoscopic, endoscopic and postendoscopic management for non-variceal and variceal subtypes. Updates in pre-endoscopic treatment include restrictive transfusion thresholds, thromboelastography-guided correction of coagulopathy, avoidance of tranexamic acid and quality of care initiatives focused on resuscitative management. Risk stratification has expanded from validated scores such as the Glasgow-Blatchford Score, to newer Horibe/Harbinger and ABC scores, complemented by machine-learning models and telemetric haemoglobin-sensing capsules. Endoscopic technology has benefited from new-generation therapeutic endoscopes and processors offering improved optics (including red dichromatic imaging), complemented by an expanding armamentarium of endoscopic accessories for primary haemostasis, not limited to through-the-scope clips, precision thermal therapies, haemostatic powders, self-assembling hydrogels, cap-mounted clips and suturing techniques for large ulcers. For variceal haemorrhage, evidence supports terlipressin infusion in favour of intermittent administration, re-evaluation of prophylactic antibiotic use and contemporary endoscopic measures such as covered self-expanding metal (Danis) stents, endoscopic ultrasound (EUS)-guided therapy for gastric varices and transvenous obliteration procedures. Postendoscopic care covers acid suppression therapy (including potassium competitive acid blockers), eradication of Helicobacter pylori , early nutrition, iron replacement, early resumption of antithrombotic therapy and rebleeding management. Key recommendations from international AUGIB guidelines are summarised and compared, future directions for research discussed and an updated management algorithm based on key advances presented herein. We hope this narrative review will provide clinicians with a summary of the latest literature and evidence-based strategies to inform clinical practice and benefit patient outcomes in AUGIB.