Hematemesis: Vomiting of blood or altered blood (“coffee grounds”) indicates bleeding proximal to ligament of Treitz.
Melena: Altered (black) blood per rectum (>100-mL blood required for one melenic stool) usually indicates bleeding proximal to ligament of Treitz but may be as distal as ascending colon; pseudomelena may be caused by ingestion of iron, bismuth, licorice, beets, blueberries, and charcoal.
Hematochezia: Bright red or maroon rectal bleeding usually implies bleeding beyond ligament of Treitz but may be due to rapid upper GI bleeding (>1000 mL).
Positive fecal occult blood test with or without iron deficiency.
Symptoms of blood loss: e.g., light-headedness or shortness of breath.
Orthostatic drop in bp >10 mmHg usually indicates >20% reduction in blood volume (± syncope, light-headedness, nausea, sweating, thirst).
BP <100 mmHg systolic usually indicates <30% reduction in blood volume (± pallor, cool skin).
Hematocrit may not reflect extent of blood loss because of delayed equilibration with extravascular fluid. Mild leukocytosis and thrombocytosis. Elevated blood urea nitrogen is common in upper GI bleeding.
Age >60 years, associated illnesses, coagulopathy, immunosuppression, presentation with shock, rebleeding, onset of bleeding in hospital, variceal bleeding, endoscopic stigmata of recent bleeding (e.g., “visible vessel” in ulcer base [see below]).
Peptic ulcer (accounts for ~50%), gastropathy (alcohol, aspirin, NSAIDs, stress), esophagitis, Mallory-Weiss tear (mucosal tear at gastroesophageal junction due to retching), gastroesophageal varices.
Swallowed blood (nosebleed); esophageal, gastric, or intestinal neoplasm; anticoagulant and fibrinolytic therapy; hypertrophic gastropathy (Ménétrier’s disease); aortic aneurysm; aortoenteric fistula (from aortic graft); arteriovenous malformation; telangiectases (Osler-Weber-Rendu syndrome); Dieulafoy lesion (ectatic submucosal vessel); vasculitis; connective tissue disease (pseudoxanthoma elasticum, Ehlers-Danlos syndrome); blood dyscrasias; neurofibroma; amyloidosis; hemobilia (biliary origin).
After hemodynamic resuscitation (see below and Fig. 41-1).
Suggested algorithm for pts with acute upper GI bleeding. Recommendations on level of care and time of discharge assume pt is stabilized without further bleeding or other concomitant medical problems. PPI, proton pump inhibitor.
History and physical examination: Drugs (increased risk of upper and lower GI tract bleeding with aspirin and NSAIDs), prior ulcer, bleeding history, family history, features of cirrhosis or vasculitis, etc. Hyperactive bowel sounds favor upper GI source.
Nasogastric aspirate for gross blood, if source (upper versus lower) not clear from history; may be falsely negative in up to 16% of pts if bleeding has ceased or duodenum is the source. Testing aspirate for occult blood is meaningless.