← Diagnosis and Management Guides
Upper GI Bleeding
Key considerations: Variceal hemorrhage, Aortoenteric fistula, Perforated ulcer
Cannot miss
- Variceal hemorrhage
- Aortoenteric fistula
- Perforated ulcer
Likely diagnoses
- Peptic ulcer disease
- Gastritis/erosions
- Mallory-Weiss tear
- Esophagitis
Red flags
- Hemodynamic instability
- Massive hematemesis
- Liver disease/varices
- Anticoagulant use
Workup
- history: Hematemesis vs melena, NSAID use, alcohol, liver disease, prior GI bleed; exam: Hemodynamic status, abdominal exam, rectal exam; labs: CBC, BMP, coags, type and screen/crossmatch, LFTs; imaging: EGD within 24 hours (12 hours if high risk); bedside: NG lavage controversial but may guide timing
Management
- immediate: IV access x2 large bore, crystalloid resuscitation; Transfuse pRBC if Hgb <7 (or <9 if CAD); PPI drip: pantoprazole 80mg IV bolus then 8mg/hr; general: Octreotide if variceal bleed suspected; Reverse anticoagulation if indicated; EGD with hemostasis
Disposition
- admit: All significant upper GI bleeds; ICU if hemodynamically unstable or variceal; discharge: Low-risk GBS 0: can consider discharge with PPI and GI follow-up; consults: GI for EGD, surgery if refractory bleeding
Clinical pearls
- Glasgow-Blatchford Score 0 = very low risk, may be safely discharged
- Restrictive transfusion (Hgb <7) improves outcomes in non-cardiac patients
Source and review
- ACG Upper GI Bleeding Guidelines 2021. Last reviewed: 2024-11-01