← Diagnosis and Management Guides
GI Bleeding
Key considerations: Massive hemorrhage with hemodynamic instability, Variceal bleeding (esophageal varices), Aortoenteric fistula
Cannot miss
- Massive hemorrhage with hemodynamic instability
- Variceal bleeding (esophageal varices)
- Aortoenteric fistula
- Perforated peptic ulcer with bleeding
- Ruptured AAA presenting as GI bleed
Likely diagnoses
- Peptic ulcer disease (most common upper GI bleed)
- Diverticular bleed (most common lower GI bleed)
- Hemorrhoids
- Mallory-Weiss tear
- Esophagitis / Gastritis
- Colon polyps / cancer
- Angiodysplasia
Red flags
- Hematemesis (upper GI bleed)
- Melena (upper or proximal GI bleed)
- Hematochezia with hemodynamic instability (massive upper GI bleed)
- Syncope or presyncope
- Tachycardia or hypotension
- Known liver disease / varices
- Anticoagulant use
- Prior aortic graft (aortoenteric fistula)
Workup
- history: Hematemesis, melena, hematochezia, or coffee-ground emesis; Quantity estimate and duration; Medications: NSAIDs, aspirin, anticoagulants, antiplatelets; Alcohol use, liver disease history; Prior GI bleeds, endoscopies, surgeries; Prior aortic graft surgery (aortoenteric fistula — 100% fatal if missed); Abdominal pain, weight loss (malignancy); exam: Vital signs: orthostatic changes, tachycardia, hypotension; Abdominal: tenderness, distension, peritoneal signs; Rectal exam: stool color (melena, bright red blood, occult blood positive); Stigmata of liver disease: jaundice, ascites, spider angiomata, palmar erythema; Skin: pallor, petechiae (coagulopathy); labs: CBC: Hgb (initial Hgb may be normal in acute bleed — not yet equilibrated); BMP: BUN/Cr (elevated BUN with normal Cr suggests upper GI bleed — absorbed blood protein); Coagulation: PT/INR, aPTT; Type and crossmatch — always; Liver function tests if liver disease suspected; Lactate: marker of tissue perfusion; imaging: CXR: free air if perforation suspected; CT angiography: active bleeding localization if massive hemorrhage and endoscopy cannot be performed; Nuclear medicine tagged RBC scan: intermittent slow bleeding; bedside: NG lavage: controversial but can help localize bleed (grossly bloody = upper GI bleed); Point-of-care hemoglobin; FAST exam if concern for free fluid / perforation
Management
- immediate: 2 large bore IVs (16-18G) or central line; Type and crossmatch immediately; Fluid resuscitation with crystalloid as bridge to blood products; Activate MTP if hemodynamically unstable with ongoing bleeding; Reverse anticoagulation if applicable; general: Restrictive transfusion: target Hgb ≥7 (≥9 if active ischemia or massive bleeding); IV PPI: pantoprazole 80mg bolus then 8mg/hr drip (if upper GI bleed suspected); GI consult for endoscopy within 24 hours (urgent if unstable); NPO in anticipation of endoscopy; specific: diagnosis: Variceal Bleeding; steps: Octreotide 50mcg IV bolus, then 50mcg/hr drip; IV antibiotics: ceftriaxone 1g IV (reduces mortality in cirrhotic GI bleed); Emergent EGD for band ligation; Balloon tamponade (Blakemore tube) if uncontrolled and endoscopy not immediately available; TIPS if refractory; diagnosis: Peptic Ulcer Bleed; steps: IV PPI drip; Endoscopy within 24 hours — urgent if high-risk features; Endoscopic therapy: epinephrine injection, clips, thermal coagulation; Test for H. pylori; diagnosis: Lower GI Bleed; steps: Most are self-limited — conservative management; If hemodynamically significant: CT angiography for localization; Colonoscopy after bowel prep (when stable); IR embolization if active bleeding identified on CTA
Disposition
- admit: All upper GI bleeds requiring endoscopy; Hemodynamic instability; Hgb drop requiring transfusion; Anticoagulated patient with GI bleed; Variceal bleed — ICU; Need for endoscopy, colonoscopy, or intervention; discharge: Minor rectal bleeding with hemorrhoids on exam, stable Hgb; Stable lower GI bleed with outpatient colonoscopy scheduled; Follow-up with GI within 1 week; consults: GI: all upper GI bleeds, significant lower GI bleeds; General surgery: perforation, failed endoscopic therapy; Interventional radiology: embolization for uncontrolled or localized bleeding; Vascular surgery: aortoenteric fistula
Clinical pearls
- Initial Hgb may be NORMAL in acute hemorrhage — blood has not yet equilibrated. Trend serial Hgb.
- Elevated BUN with normal Creatinine = upper GI bleed (digested blood protein absorbed in small intestine)
- Prior aortic graft + GI bleed = aortoenteric fistula until proven otherwise — often presents with herald bleed followed by massive hemorrhage
- Ceftriaxone in cirrhotic GI bleed reduces mortality — give antibiotics to ALL cirrhotic patients with GI bleed
- Restrictive transfusion (Hgb trigger 7) has better outcomes than liberal transfusion in GI bleed (Villanueva trial)
Source and review
- ACG Upper GI Bleed Guidelines 2021, ACG Lower GI Bleed Guidelines 2023, AASLD Variceal Bleed Guidelines. Last reviewed: 2024-11-01