Hematemesis vs coffee-ground vs melena vs hematochezia — map the likely level
NSAIDs, anticoagulants, antiplatelets, alcohol, cirrhosis
Prior ulcers, H. pylori, AAA repair, radiation, IBD
Volume-loss symptoms
syncope, angina with anemia
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Your objective: explain the approach, recognize important warning signs, then test your recall.
Abbreviations explained
- ACS
- Acute coronary syndrome
- OMI
- Occlusion myocardial infarction
- ECG
- Electrocardiogram
- PE
- Pulmonary embolism
- POCUS
- Point-of-care ultrasound
- QTc
- QT interval corrected for heart rate
- LBBB
- Left bundle branch block
- RBBB
- Right bundle branch block
- hs-cTn
- High-sensitivity cardiac troponin
- CTA
- Computed tomography angiography
- ICU
- Intensive care unit
Filter
The jobResuscitate, risk-stratify, find the source.
- Resuscitate first: two large-bore IVs, hemodynamics over the first hematocrit.
- Upper vs lower from the story; variceal pathway changes drugs and endoscopy timing.
- Risk-stratify: Glasgow-Blatchford 0–1 can leave (ACG 2021).
- Restrictive transfusion (Hb 7; ~8 if CVD); do not over-transfuse varices.
GI bleeding is resuscitation first, diagnosis second.
Hemodynamics beat the hematocrit (it lags for hours). Estimate upper vs lower from the story, risk-stratify (Glasgow-Blatchford for UGIB; Oakland for selected LGIB), and know the variceal pathway — it changes drugs and endoscopy timing.
Variceal hemorrhage Critical
Key: Cirrhosis + hematemesis: vasoactive drug (octreotide; terlipressin where available) + ceftriaxone + endoscopy within 12 h; restrictive transfusion (Hb 7–8 g/dL).
Aortoenteric fistula Critical
Key: Prior AAA repair + any GI bleed = fistula until excluded (CTA / surgery).
Massive lower GI bleed (diverticular, angiodysplasia) Critical
Key: Instability directs CTA → IR/endoscopy over colonoscopy-first.
Mesenteric ischemia with bleeding Critical
Key: Bloody stool + pain out of proportion in a vasculopath.
Anticoagulant-associated bleeding Critical
Key: Agent-specific reversal for life-threatening hemorrhage; balance thrombosis risk (ACG/CAG 2022).
Ischemic colitis / IBD flare Emergent
Key: Pain + bloody diarrhea; steroids for IBD per severity.
Peptic ulcer / gastritis / anorectal sources Common
Key: Most frequent; PPI after endoscopy per ACG; outpatient endoscopy if GBS 0–1.
Tick what your patient has — the banner updates as you go.
Vitals and orthostatics — tachycardia is the earliest reliable sign
Stigmata of liver disease
caput, ascites, asterixis
Rectal exam
color, mass, trauma
Skin
petechiae (thrombocytopenia), telangiectasias
Bedside
- Two large-bore IVs; crossmatch early
- POCUS for ascites; NG lavage is not routinely recommended
Labs
- CBC (expect lag), type & crossmatch, coagulation/INR, BUN/Cr (BUN rise suggests upper source), lactate
- Glasgow-Blatchford for UGIB disposition; LFTs if liver disease
Imaging / scope
- Upper endoscopy within 24 h (within 12 h if variceal suspected)
- CTA for massive/obscure LGIB → IR; colonoscopy for stable LGIB after prep
Medication safety reminder
Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.
Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.
Discharge
- Glasgow-Blatchford 0–1 (ACG 2021: very-low-risk UGIB, ≤1% need for intervention) — outpatient endoscopy pathway, stable vitals, reliable follow-up.
Admit (ward / HDU)
- GBS ≥2, identified stable source, anticoagulation management needed.
ICU / endoscopy-IR activation
- Hemodynamic instability, active transfusion need, suspected variceal bleed, aortoenteric fistula.
Use objective reassessment and the local pathway.
Before the next decision · reassess and hand over
Use these learning prompts with the presentation’s pathway. They are not discharge criteria.
- Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
- Warning signs for GI Bleeding:
- Hemodynamic instability or orthostatic symptoms
- Active hematemesis or massive hematochezia
- Cirrhosis with any upper GI bleeding
- Known AAA repair with any bleed
- Melena + syncope (brisk upper source)
- Anticoagulation with life-threatening hemorrhage
- Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
- Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
- Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Clinical Pearls
- Hemodynamics beat the hematocrit — the first Hb lags 12–24 h.
- Glasgow-Blatchford 0–1 can leave for outpatient endoscopy (ACG 2021).
- Restrictive transfusion: Hb 7 g/dL (≈8 if cardiovascular disease).
- Variceal bleed: vasoactive drug + ceftriaxone + endoscopy within 12 h; do not over-transfuse.
Pitfalls
- The hematocrit lags 12–24 h — a normal first value means nothing acutely.
- Melena can come from the right colon; hematochezia can be a brisk upper bleed.
- Restrictive transfusion (Hb 7 g/dL; ~8 g/dL if cardiovascular disease) improves UGIB outcomes (Villanueva NEJM 2013; ACG 2021).
- Over-transfusing variceal bleeding raises portal pressure and rebleeding (Baveno VII).
- Pre-endoscopic PPI has no ACG recommendation for or against — do not let it delay endoscopy.
- NG lavage does not reliably risk-stratify and is not required.
PRACTICE REFRESHER
Rapid recall
Test your first action and the dangerous diagnoses before revealing the answer.
01 · First move
Before you scroll, what needs to happen first?
Resuscitate first: two large-bore IVs, hemodynamics over the first hematocrit.
02 · Immediate threats
Name at least two diagnoses that cannot wait.
Variceal hemorrhage · Aortoenteric fistula · Massive lower GI bleed (diverticular, angiodysplasia)
PRIVATE TO THIS DEVICE
Your learning note
Capture a weak point, a teaching pearl, or a question to take to your next shift.
Review schedule starts when marked reviewed
Foundational references below. No separate topic-specific guideline check is recorded here.
- Rosen’s Emergency Medicine, 10th ed. (2023) — GI bleeding
- ACG 2021 Clinical Guideline: Upper GI and Ulcer Bleeding (Laine et al.) — GBS 0–1 discharge; Hb 7 g/dL
- Baveno VII (2022) portal hypertension consensus; AASLD variceal hemorrhage guidance