In the ICU patient, the diagnosis of bleeding due to peptic ulceration is made by bloody/coffee-ground nasogastric aspirate, emesis, or melena. Upper endoscopy is warranted when the bleeding is associated with decreasing hematocrit and/or hemodynamic instability. If active bleeding or signs of recent bleeding are identified during endoscopy, hemostatic therapies can be performed, including epinephrine injection to cause vasospasm, placement of clips to directly occlude the vessel, or heater probe application to coagulate the vessel. Nonsteroidal anti-inflammatory drug/aspirin treatment should be stopped in patients diagnosed with upper gastrointestinal bleeding. In addition, acid reduction must be instituted because lower gastric pH may cause clot lysis. Evidence supports the use of intravenous proton pump inhibitor in this setting. Despite aggressive endoscopic and medical management, rebleeding occurs in 15% to 20% of patients; therefore surgical consultation is imperative in all patients requiring urgent upper endoscopy.