GI bleed

— SX:
Black/tarry (melena) → UGIB (PUD, gastritis, varices)
Vomiting blood (hematemesis) → UGIB
Bright red blood (hematochezia) → LGIB
Maroon/mixed → could be either (brisk UGIB or proximal LGIB)
Any dizziness, lightheadedness, passing out?” → hemodynamic compromise
“How much blood?” → large volume = diverticulosis or varices
“Shortness of breath, chest pain?” → anemia severity
((UGIB))
NSAIDs + Epigastric Pain,Better/worsen with food?(duodena/gastric) → PUD
Alcohol / ICU / NSAIDs → Gastritis
liver disease?”alcohol use?Prior variceal bleed? →  Varices
Vomiting BEFORE bleed → Mallory-Weiss
Pain with swallowing? Immunocompromised? → Esophagitis
Weight loss → Gastric Cancer
((LGIB))
Painless + large volume → Diverticulosis
Recurrent intermittent → Angiodysplasia
Blood on wiping → Hemorrhoids (Straining?)
Pain BEFORE bleeding → Ischemic Colitis (Recent dehydration or low BP?)
Chronic diarrhea → IBD (Mucus in stool?)
Fever?, Recent travel or food? → Infectious Colitis
Weight loss?Change in bowel habits?Family history?**→ Colorectal Cancer

— HX: PUD (H. pylori/NSAIDs), chronic NSAID/steroid use, alcohol use disorder, cirrhosis/portal HTN with prior variceal bleed, GERD/esophagitis (± immunocompromised), malignancy,CKD/aortic stenosis (angiodysplasia), diverticulosis, hemorrhoids/constipation, vascular disease/hypotension (ischemic colitis), IBD
— W/U: CBC(Hgb), CMP(BUN/Cr ratio (>20 suggests UGIB), PT/INR, PTT, Type & Screen, Lactate, EGD vs colonoscopy, Unstable → CTA → IR embolization
—MEDs:
— DDX- UGIB (PUD, Gastritis, Esophageal Varices, Mallory-Weiss Tear, Esophagitis, Gastric Cancer) LGIB (Diverticulosis, Angiodysplasia (AVMs), Hemorrhoids, Colorectal Cancer,Ischemic Colitis, Inflammatory Bowel Disease (UC/Crohn’s), Infectious Colitis

Plan 

GI consult (EGD within 12-24 hrs, Stable → colonoscopy) 
2 large-bore IVs (16–18G)
Transfuse if Hgb <7 (<8 if CAD)
IVF as needed Q6->Q12->QD
Trend CBC 
Hold / reverse anticoagulation Restart 3–7 days after hemostasis
Pantoprazole 80 mg IV bolus → 8 mg/hr infusion 
Octreotide (if varices suspected OR undifferentiated severe UGIB) bolus of 50 mcg followed by continuous infusion at rate of 25 mcg/hr
Antibiotics (ONLY if cirrhosis/varices) Ceftriaxone 1 g IV daily x 7 days
NPO
Use SCDs until bleeding controlled for DVT prophy 
Avoid NSAIDs 

UGIB. (Melena / hematemesis) ↑BUN/Cr ratio (>20 suggests UGIB)

— PUD (H. pylori, NSAIDs)
SX: epigastric pain, melena, 
HX: NSAIDs, H. pylori 
W/U: CBC,BMP,H. pylori testing, 
TX: IV PPI (pantoprazole)→ endoscopic clipping/cautery → treat H. pylori, Stop NSAIDs

NSAIDs?Burning epigastric pain?(ulcer), Pain better with food?(duodenal ulcer), Pain worse with food (gastric ulcer) melena? ± hematemesis?

— Gastritis / Erosive Gastropathy (alcohol, NSAIDs, stress (ICU), steroids) 
SX: Diffuse epigastric discomfort or burning, mild hematemesis, nausea, dyspepsia
HX: alcoholism , NSAIDs, ICU/stress 
W/U: CBC,BMP, 
Meds: Steroids, NSAIDs
TX: IV PPI (pantoprazole)→ endoscopic clipping/cautery, Remove offending agent

Alcohol use? Steroids NSAIDs?

— Esophageal Varices
SX: Usually NO pain, massive hematemesis, dizziness, Hypotension/tachycardia
HX: cirrhosis, alcohol use, hepatitis, previous varices bleed 
W/U: CBC, CMP, Coag 
MEDs: 
Tx: bolus of 50 mcg followed by continuous infusion at rate of 25 mcg/hr,IV ceftriaxone, EGD with band ligation, Volume resuscitation if needed 

Hx of cirrhosis , Hx varices bleed? 

— Mallory-Weiss Tear (retching → hematemesis) 
SX: Chest or epigastric pain after vomiting, hematemesis after vomiting/retching
HX:alcohol, forceful emesis
W/U: CBC, CMP,
MEDs: 
Tx: IV PPI ± endoscopic therapy if persistent→ linear tear

alcohol use? forceful emesis? vomiting before the bleeding?

— Esophagitis (GERD, infections (CMV, HSV in immunocompromised)),
SX:Retrosternal, odynophagia(chest pain with swallowing), mild bleeding
HX:Painful swallowing, GERD, immunocompromised (HIV, chemo, steroids?)
W/U:CBC, CMP,
MEDs: 
Tx:PPI-> EGD-> Treat cause (CMV → ganciclovir, HSV → acyclovir)

chest pain with swallowing?  Burning chest discomfort

— Gastric Cancer (malignancy ulceration, weight loss, anemia)
SX:Vague epigastric discomfort, Weight loss, Early satiety, occult bleeding, fatigue, IDA
HX:Iron deficiency anemia 
W/U: CBC,BMP, EGD + biopsy
MEDs: 
Tx: EGD + biopsy

Unintentional weight loss? Early satiety( mass effect),

LGIB  (Bright red blood)

— Diverticulosis (painless hematochezia, sudden) 
SX:sudden painless hematochezia
HX:older age
W/U: CBC,BMP,colonoscopy (after stabilization) ± CTA
MEDs: 
Tx:Often self-limited, Colonoscopic clipping, IR embolization if ongoing bleed

Large-volume bright red blood? prior similar episodes?( common)

— Angiodysplasia (AVMs) 
SX:intermittent painless bleeding
HX:elderly, CKD, aortic stenosis, colonoscopy?
W/U:CBC,BMP
MEDs: 
Tx:Stable → colonoscopy (APC (Argon Plasma Coagulation), Unstable/ongoing brisk bleed → CTA → IR

Recurrent bleeding episodes

— Hemorrhoids (bright red blood on toilet paper) 
SX:bright red blood on wiping, internal: no pain, External: perianal pain/itching
HX: constepation  
W/U:CBC,BMP
MEDs: 
Tx:Fiber, stool softeners , Banding if persistent

bright red blood on wiping? Straining? (cause)

— Colorectal Cancer (weight loss, iron deficiency anemia, occult bleed)
SX: vague abdominal discomfort, Weight loss?occult bleeding, fatigue
HX:CBC,BMP
W/U:colonoscopy + biopsy
MEDs: 
Tx:colonoscopy + biopsy

Change in bowel habits?Family history?Weight loss?

— Ischemic Colitis (painful hematochezia), hypoperfusion (shock, atherosclerosis)
SX:painful hematochezia + abdominal pain
HX: hypotension, vascular disease
W/U:CBC,CMP.latate 
MEDs: 
Tx:IV fluids, Bowel rest, Broad-spectrum antibiotics

painful hematochezia + abdominal pain? pain start BEFORE bleeding? Recent dehydration or low BP?

— Inflammatory Bowel Disease (UC/Crohn’s)
SX: UC: LLQ cramping, Crohn’s: RLQ pain , chronic diarrhea, blood, mucus
HX:
W/U:CBC,CMP,ESR/CRP,colonoscopy
MEDs: 
Tx:colonoscopy, (steroids ± biologics)

Mucus in stool?(UC), UC: LLQ cramping, Crohn’s: RLQ pain

— Infectious Colitis (fever, diarrhea, recent travel/food)
SX:Diffuse abdominal cramping, diarrhea + fever + blood
HX:
W/U:CBC, CMP , stool PCR/culture
MEDs: 
Tx:supportive ± antibiotics 

fever? Recent travel or food exposure? diarrhea? Bold?