Non-portal hypertension-related upper gastrointestinal bleeding (UGIB) remains one of the most common emergencies in gastroenterology, accounting for the majority of UGIB cases in Western countries.Its incidence is estimated at 50-150 cases per 100.000 population per year, with a mortality rate that remains between 5% and 10% despite advances in diagnostic and therapeutic strategies. Clinical presentation is often abrupt, typically as hematemesis or melena, requiring prompt and structured management including initial resuscitation, diagnostic and therapeutic endoscopy, and secondary prevention.In recent years, the therapeutic armamentarium available to the endoscopist has expanded with the introduction of innovative devices such as over-the-scope clips, hemostatic powders, and gels. Several randomized trials have refined the optimal timing of endoscopy and compared the efficacy of various techniques.

Acute gastrointestinal bleeding is a medical emergency in which early management, including pre-hospital care, is crucial for prognosis. The patient's history and clinical examination should focus on identifying signs of severity requiring immediate medical intervention. The pharmalogical treatment of upper gastrointestinal bleeding depends on the suspected cause: proton pump inhibitors for peptic ulcers, splanchnic vasoconstrictors and antibiotics in cases of portal hypertension. Risk stratification using validated scoring systems helps identify low-risk patients eligible for outpatient management. A restrictive transfusion strategy (hemoglobin < 7 g/dL) is recommended. For upper gastrointestinal bleeding, endoscopy should be performed within 24 hours (within 12 hours in patients with portal hypertension). For lower gastrointestinal bleeding, computed tomography angiography is useful for locating active bleeding, while colonoscopy remains the gold standard procedure.

Acute variceal bleeding treatment in patients with portal hypertension combines vasoactive drugs, prophylactic antibiotics, hepatic encephalopathy prophylaxis and upper gastrointestinal endoscopy for variceal treatment (elastic band ligation and/or tissue adhesive injection), on top of non-specific measures. Failure to control bleeding must lead to salvage TIPS (Transjugular Intrahepatic Portosystemic Shunt) discussion, after esophageal tamponade (balloon or stent).Pre-emptive TIPS within 72h must systematically be considered in high-risk patients to reduce rebleeding and mortality. Pre-emptive TIPS must also be discussed in case of gastric variceal bleeding.Following the acute bleeding episode, secondary prophylaxis combines non-selective betablockers and recurrent endoscopic treatments (except after TIPS). Liver transplantation must be discussed in certain cases of refractory bleeding or early relapse after TIPS implantation.

Upper gastrointestinal bleeding (UGIB) is a frequent cause of emergency department admission and is most commonly attributed to peptic ulcer disease or portal hypertension-related varices. In critically ill patients, however, pulmonary bleeding may be misinterpreted as hematemesis when blood is swallowed or expelled during retching or airway compromise. In patients undergoing long-term hemodialysis, catheter-related central venous thrombosis can precipitate atypical bleeding presentations. We report the case of a 45-year-old man with chronic kidney disease on maintenance hemodialysis who presented with sudden-onset recurrent hematemesis and hemodynamic instability. Initial evaluation suggested severe UGIB, prompting endotracheal intubation, vasopressor support, and urgent upper endoscopy. Endoscopy demonstrated small esophageal varices and erosive gastropathy without evidence of active bleeding. Subsequent chest computed tomography revealed superior vena cava thrombosis with extensive mediastinal collateral circulation and imaging findings consistent with pulmonary hemorrhage. Bronchoscopy confirmed active bleeding originating from the right bronchial tree, establishing the diagnosis of pulmonary hemorrhage secondary to superior vena cava thrombosis. This case underscores an important diagnostic pitfall: severe pulmonary hemorrhage may mimic UGIB, particularly when initial endoscopic evaluation is non-diagnostic. In hemodialysis patients, superior vena cava thrombosis and collateral vessel formation should be considered as potential mechanisms of airway bleeding even in the absence of classic superior vena cava syndrome. Early thoracic imaging and bronchoscopy are essential when endoscopic findings do not account for persistent or severe hematemesis to prevent diagnostic delays and inappropriate gastrointestinal interventions.