GI Bleed — Upper (UGIB)

Bleeding proximal to the ligament of Treitz

Symptoms / Associated Sx

• Hematemesis (bright red blood or coffee-ground emesis)

• Melena (black, tarry, foul-smelling stool)

• Epigastric pain, nausea

• Lightheadedness, presyncope, syncope

• Signs of hemodynamic instability: tachycardia, hypotension, pallor, diaphoresis

Denies

• Hematochezia without hemodynamic instability (rules out brisk UGIB presenting as LGIB)

• Jaundice or abdominal distension (rules out variceal bleed from cirrhosis/portal HTN)

• Dysphagia, odynophagia (rules out esophageal malignancy or Mallory-Weiss tear as primary)

• NSAID/steroid/anticoagulant use (reduces PUD-related bleeding risk if truly absent)

• Prior GI bleed or known varices (lowers rebleeding risk if absent)

Social History (SHx)

Heavy alcohol use (varices, gastropathy), active tobacco use (PUD risk), NSAID/aspirin overuse; note living situation if relevant to follow-up endoscopy.

Main Etiology

• Peptic ulcer disease — most common (~50%)

• Esophageal/gastric varices (portal hypertension/cirrhosis)

• Mallory-Weiss tear (forceful vomiting)

• Esophagitis / erosive gastritis

• Dieulafoy lesion (large submucosal vessel, often missed)

• Gastric antral vascular ectasia (GAVE / "watermelon stomach")

• Malignancy (gastric or esophageal)

• Aortoenteric fistula (post-aortic graft — must not miss)

DATA

• CBC (hemoglobin/hematocrit trend, thrombocytopenia)

• BMP / CMP (BUN elevated in UGIB from blood digestion; BUN:Cr ratio >20 suggests UGIB)

• Coagulation panel — PT/INR, PTT (coagulopathy, anticoagulation status)

• Type and screen / crossmatch (transfusion readiness)

• LFTs + albumin (liver disease, synthetic function)

• Lactate (tissue perfusion, shock)

• EGD — upper endoscopy: diagnostic and therapeutic (within 24h; within 12h if high-risk/active bleed)

• NG lavage — not routinely required but may help localize if bleeding source uncertain

• IV access: two large-bore peripheral IVs or central line if unstable

Home Meds

• NSAIDs / aspirin / COX-2 inhibitors (PUD risk — hold)

• Anticoagulants: warfarin, DOACs, heparin (reversal consideration)

• Antiplatelets: clopidogrel, ticagrelor (hold vs. continue if recent stent)

• Corticosteroids (increases GI bleeding risk)

• Beta-blockers (non-selective: propranolol/nadolol for varices — continue or restart)

• PPIs at home (partial protection — switch to IV)

• SSRIs (mild platelet inhibition — note)

Plan — UGIB

• Resuscitation:

  • 2 large-bore IVs; NS or LR bolus for hemodynamic instability

  • Transfuse pRBCs: target Hgb ≥7 g/dL (≥8 if ACS or hemodynamically unstable)

  • Correct coagulopathy: FFP if INR >1.5; platelets if <50k; vitamin K if on warfarin

  • Reverse anticoagulation if active significant bleed (4-factor PCC for warfarin; andexanet alfa for factor Xa inhibitors)

  • NPO; elevate HOB

• Acid suppression (PPI):

  • Non-variceal: Pantoprazole 80 mg IV bolus → 8 mg/hr continuous infusion × 72h (high-risk lesions post-EGD)

  • Low-risk/stable: Pantoprazole 40 mg IV q12h or 40 mg PO BID

  • Step-down: Pantoprazole 40 mg PO daily (discharge)

• Variceal bleed (if suspected/confirmed):

  • Octreotide 50 mcg IV bolus → 50 mcg/hr infusion × 3–5 days

  • Ceftriaxone 1 g IV daily × 7 days (SBP prophylaxis — reduces mortality)

  • Avoid beta-blockers acutely; restart non-selective BB after stabilization

  • TIPS if refractory variceal bleed

• Endoscopy:

  • Urgent EGD within 24h for all UGIB

  • Within 12h if: active hematemesis, hemodynamic instability, suspected variceal bleed, Hgb drop >2 g/dL

  • Erythromycin 250 mg IV 30–90 min before EGD (improves gastric visualization)

• Hold NSAIDs, anticoagulants, antiplatelets — reassess with GI/cardiology (if recent stent)

• H. pylori testing (biopsy at EGD or urea breath test) — treat if positive

• Monitor: serial CBC q6–8h, vital signs, urine output

• Trend Hgb, BUN:Cr ratio, lactate

• GI consult (urgent), Surgery consult if EGD fails hemostasis

• PT/OT evaluation if deconditioning, falls, or prolonged hospitalization

• Daily labs: CBC, BMP, coags until stable

• Discharge recommendations:

  • PPI PO daily (minimum 4–8 weeks for PUD; ongoing for high-risk)

  • H. pylori treatment if positive (triple or quadruple therapy × 14 days)

  • Avoid NSAIDs; counsel on alcohol cessation

  • Repeat EGD in 8–12 weeks for gastric ulcer to rule out malignancy

  • Follow-up GI within 2–4 weeks

⚠ Red Flags — UGIB

• HR >100, SBP <90, orthostatic changes → hemorrhagic shock → ICU

• Active hematemesis with airway compromise → immediate intubation for airway protection before EGD

• Hgb drop >2 g/dL acutely or ongoing transfusion requirement

• Suspected aortoenteric fistula (prior aortic graft + GI bleed) → CT angio immediately + surgery

• Refractory variceal bleed → TIPS, Sengstaken-Blakemore tube as bridge

• Failed endoscopic hemostasis → IR embolization or surgical intervention

• Glasgow-Blatchford ≥7 or Rockall score ≥3 → high rebleed risk → ICU-level monitoring

Senior IM Resident Pearls — UGIB

• Glasgow-Blatchford Score (GBS): Use pre-endoscopy. Score 0 = safe for outpatient EGD. Score ≥7 = high risk, admit. Inputs: BUN, Hgb, SBP, HR, melena, syncope, hepatic/cardiac disease.

• Rockall Score: Pre- and post-EGD versions. Predicts rebleeding and mortality. Post-EGD score >5 = high rebleed risk.

• BUN:Cr ratio >20 strongly suggests UGIB (blood is digested → urea absorbed) — useful when source uncertain.

• Hgb may be falsely normal in acute bleed before hemodilution — don't be reassured by a "normal" initial Hgb; trend it.

• Erythromycin before EGD is evidence-based — it prokinetic clears blood, improves visualization, reduces need for repeat scope.

• Restrictive transfusion strategy (Hgb ≥7) is associated with better outcomes in UGIB — including variceal bleeds. Avoid overtransfusing.

• Avoid beta-blockers acutely in variceal bleed — they mask tachycardia (blunts resuscitation monitoring).

• Common mistake: Giving PPI bolus only without continuous infusion for high-risk lesions (visible vessel, adherent clot) — infusion is required post-endoscopy × 72h.

• Common mistake: Forgetting SBP prophylaxis (ceftriaxone) in cirrhotic UGIB — it reduces mortality, not just infection.

ADMISSION ORDERS

Labs

STAT on Admission

• CBC with diff

• CMP (or BMP + LFTs)

• PT/INR

• PTT

• Type & Screen

• Type & Cross (2–4 units PRBC if significant bleed)

• Lactate

• Magnesium

• Phosphorus

Additional Labs

• Iron studies (if chronic bleed suspected)

• H. pylori testing (usually via EGD biopsy)

• Ethanol level (if alcohol history)

• VBG/ABG if unstable

• Troponin if chest pain, CAD, or severe anemia

• Pregnancy test if applicable

Trending Labs

• CBC q6–8h until stable

• BMP daily

• PT/INR daily if elevated

• Lactate q4–6h if shock

• Hgb/Hct after each transfusion

Imaging

Usually Not Needed

• No routine CT scan

If Source Unclear / Concern for Other Pathology

• CT Abdomen/Pelvis

• CT Angiography Abdomen/Pelvis (active bleed)

Must Not Miss

• CTA Abdomen/Pelvis STAT

  • Prior AAA repair/aortic graft

  • Concern for aortoenteric fistula

Portable Imaging

• CXR

  • If aspiration suspected

  • Prior to intubation

  • Line placement confirmation

Procedures

Immediately

• 2 large-bore IVs (16–18 gauge)

• Cardiac monitor

• Continuous pulse ox

• Strict I&O

• Daily weights

If Unstable

• Central line

• Arterial line

• Foley catheter

Definitive

• EGD within 24 hours

• EGD within 12 hours if:

  • Active hematemesis

  • Hemodynamic instability

  • Suspected varices

Medications

Resuscitation

• LR bolus 1–2 L IV
  OR

• NS bolus 1–2 L IV

Blood Products

• PRBC transfusion

  • Goal Hgb >7

  • Goal Hgb >8 if ACS/CAD

Coagulopathy

• Vitamin K 10 mg IV

• FFP if INR >1.5 with active bleed

• Platelets if <50,000

• 4-factor PCC if warfarin-associated bleed

• Andexanet alfa if Factor Xa inhibitor bleed

PPI Therapy

High-Risk / Active UGIB

• Pantoprazole 80 mg IV bolus

• Then 8 mg/hr infusion x72 hr

Stable / Lower Risk

• Pantoprazole 40 mg IV q12h

Step Down

• Pantoprazole 40 mg PO daily

If Variceal Bleed Suspected

Octreotide

• 50 mcg IV bolus

• Then 50 mcg/hr infusion

• Continue 3–5 days

SBP Prophylaxis

• Ceftriaxone 1 g IV daily x7 days

Later

• Restart propranolol/nadolol after stabilization

Pre-EGD

Erythromycin

• 250 mg IV once

• 30–90 minutes before EGD

Medications to Hold

• NSAIDs

• Aspirin (unless strong cardiac indication)

• Clopidogrel

• Ticagrelor

• Warfarin

• DOACs

• Heparin

• DVT prophylaxis initially until bleed controlled

Consults

Always

• Gastroenterology (urgent)

Sometimes

• ICU

  • Shock

  • Massive transfusion

  • Active hematemesis

  • Intubation

If EGD Fails

• Interventional Radiology

• General Surgery

Additional

• Cardiology

  • Recent stent

  • Need help with antiplatelet management

• Hepatology

  • Cirrhosis/varices

• PT/OT

  • Deconditioning/falls

Nursing Orders

• Admit telemetry

• NPO

• Elevate HOB >30°

• Vital signs q4h (or more frequent)

• Strict I&O

• Fall precautions

• Monitor stool color and frequency

• Notify MD immediately for:

  • SBP <90

  • HR >110

  • New hematemesis

  • Syncope

  • Hgb drop >2

GI Bleed — Lower (LGIB)

Bleeding distal to the ligament of Treitz

Symptoms / Associated Sx

• Hematochezia (bright red or mar

• oon blood per rectum)

• Blood coating stool or mixed in stool

• Crampy lower abdominal pain (colitis, ischemia)

• Change in bowel habits (suggests malignancy or colitis)

• Lightheadedness, presyncope, hemodynamic instability if brisk bleed

Denies

• Hematemesis or coffee-ground emesis (rules out UGIB source)

• Melena (rules out proximal bleed if truly absent)

• Fever, diarrhea, recent travel / sick contacts (rules out infectious colitis)

• Recent abdominal surgery or vascular graft (rules out aortoenteric fistula)

• Weight loss, night sweats (rules out colorectal malignancy as priority)

• Prior radiation to pelvis (rules out radiation proctitis)

Social History (SHx)

NSAID/aspirin use (diverticular, ulcer risk), anticoagulant/antiplatelet therapy, prior colonoscopy or polypectomy, smoking, alcohol, family history of colorectal cancer or IBD.

Main Etiology

• Diverticulosis — most common cause of significant LGIB (~40%)

• Colorectal malignancy / polyps

• Ischemic colitis (especially in elderly, low-flow states)

• Hemorrhoids / anal fissure (most common cause overall, usually minor)

• Inflammatory bowel disease (Crohn's, UC)

• Angiodysplasia / AVM (elderly, CKD, aortic stenosis — Heyde syndrome)

• Infectious colitis (Salmonella, C. diff, STEC)

• Radiation proctitis

• Post-polypectomy bleeding

DATA

• CBC (Hgb trend, platelet count)

• BMP / CMP (renal function, electrolytes)

• Coagulation panel — PT/INR, PTT

• Type and screen / crossmatch

• Lactate (perfusion status)

• Stool studies: C. diff toxin, culture, O&P if infectious etiology suspected

• NG lavate or EGD if brisk hematochezia + hemodynamic instability (rule out UGIB)

• Colonoscopy — gold standard diagnostic and therapeutic (after bowel prep when stabilized)

• CT angiography (CTA abdomen/pelvis) if brisk bleed, hemodynamically unstable, or unable to prep for colonoscopy — identifies bleeding rate ≥0.5 mL/min

• Tagged RBC nuclear scan (Tc-99m) — identifies slower bleeds ≥0.1 mL/min; used when CTA negative but bleed ongoing

• Rectal exam (hemorrhoids, mass, fissure)

Home Meds

• Anticoagulants (warfarin, DOACs — reversal consideration)

• Antiplatelets (aspirin, clopidogrel — hold vs. continue)

• NSAIDs (hold)

• Immunosuppressants (IBD — continue vs. hold depending on severity)

• Iron supplementation (can cause dark stool — distinguish from melena)

Plan — LGIB

• Resuscitation:

  • 2 large-bore IVs; fluid resuscitation for hemodynamic instability

  • Transfuse pRBCs: target Hgb ≥7 (≥8 if elderly, ACS, or hemodynamically unstable)

  • Correct coagulopathy: FFP if INR >1.5; platelets if <50k

  • Reverse anticoagulation if active significant bleed

  • NPO until procedure determined

• Localization and hemostasis:

  • Colonoscopy — first-line when patient stabilized + bowel prep completed; therapeutic if source found

  • CT angiography if brisk bleed or hemodynamic instability — prior to colonoscopy or surgery

  • IR-guided embolization if bleeding vessel identified on CTA and ongoing bleed

  • Surgery if all above fail or hemodynamically unstable with uncontrolled bleed

• Hold NSAIDs, anticoagulants, antiplatelets (discuss restart timing with GI/cardiology)

• Treat specific etiology:

  • IBD flare: discuss with GI — IV steroids or biologics

  • Ischemic colitis: bowel rest, IV fluids, treat underlying cause (low-flow state)

  • Infectious colitis: targeted antibiotics per culture (avoid in STEC unless severe)

• Monitor: serial CBC q6–8h, vital signs, stool output

• Trend Hgb, coags, BMP daily

• GI consult, Surgery consult if hemostasis not achieved

• PT/OT evaluation if prolonged hospitalization or deconditioning

• Trend fever curve if infectious etiology suspected

• Follow up on pending stool cultures, colonoscopy pathology

• Discharge recommendations:

  • Outpatient colonoscopy if not yet done (within 8 weeks)

  • Resume anticoagulation after discussion with GI (typically 7–10 days post-bleed)

  • High-fiber diet + stool softeners if diverticular or hemorrhoidal

  • Avoid NSAIDs

  • Follow-up GI within 2–4 weeks

  • Colorectal surgery consult if recurrent diverticular bleed (>2 episodes)

⚠ Red Flags — LGIB

• HR >100, SBP <90, active hematochezia with instability → ICU, urgent CTA, IR/surgery

• Brisk hematochezia + hemodynamic instability → rule out UGIB first (EGD before colonoscopy)

• Peritoneal signs + bloody stool → ischemic bowel perforation → emergent surgery

• Significant Hgb drop (>2 g/dL) with ongoing bleeding despite resuscitation

• Inability to achieve hemostasis endoscopically → IR embolization → surgery

• Suspected ischemic colitis with peritonitis → surgical emergency

• Aortoenteric fistula (prior aortic graft history) → CT angio immediately + surgery

Senior IM Resident Pearls — LGIB

• Brisk hematochezia can be UGIB (~10-15% of cases) — always rule out upper source with NG lavate or EGD if hemodynamically unstable.

• Oakland Score: Validated for safe discharge in LGIB. Score ≤8 → low-risk, consider outpatient management. Score >8 → admit.

• Heyde syndrome: Aortic stenosis + angiodysplasia-related GI bleed — acquired von Willebrand deficiency from high-shear flow. Treat the valve.

• Ischemic colitis classically presents in "watershed zones" (splenic flexure, rectosigmoid). Risk factors: hypotension, post-aortic surgery, cocaine use, vasopressors.

• Diverticular bleed is usually painless — if painful, suspect diverticulitis, ischemia, or IBD instead.

• Tagged RBC scan detects very slow bleeds but is poor at localizing exactly — use CTA for localization before surgery or IR.

• Common mistake: Delaying anticoagulation restart indefinitely — data supports restarting within 7–10 days in most patients; prolonged hold increases thromboembolic risk (especially AF, mechanical valves).

• Common mistake: Attributing rectal bleeding to hemorrhoids without colonoscopy in patients >45 or with alarm features — colorectal cancer must be excluded.

ADMISSION ORDERS

Labs

STAT Admission Labs

• CBC with diff

• CMP (or BMP + LFTs)

• PT/INR

• PTT

• Type & Screen

• Type & Cross (2–4 units PRBC if active bleed)

• Lactate

• Magnesium

• Phosphorus

Additional Labs (Depending on Etiology)

• ESR/CRP (IBD)

• Stool C. difficile PCR

• GI pathogen panel/stool culture

• O&P if travel/immunocompromised

• Fecal calprotectin (IBD)

• Iron studies if chronic blood loss suspected

Trending Labs

• CBC q6–8h until stable

• BMP daily

• PT/INR daily if abnormal

• Lactate q4–6h if unstable

• Hgb/Hct after transfusion

Imaging

First-Line Imaging

CTA Abdomen/Pelvis

Order if:

• Active hematochezia

• Hemodynamic instability

• Hgb rapidly dropping

• Ongoing bleed

Can localize bleeding and direct IR embolization.

Additional Imaging

Tagged RBC Scan

Order if:

• Intermittent bleeding

• CTA negative

• Bleeding continues

If Concern for Alternative Etiology

CT Abdomen/Pelvis w/ Contrast

• Colitis

• Diverticulitis

• Ischemic colitis

• Mass/malignancy

Procedures

Immediately

• Rectal exam

• Telemetry

• Continuous pulse oximetry

• Strict I&O

• Daily weights

Access

• Two large-bore IVs (16–18 gauge)

If Unstable

• Central line

• Arterial line

• Foley catheter

Definitive Procedure

Colonoscopy

• Bowel prep first

• Diagnostic and therapeutic

Common prep:

• GoLytely 4–6 L PO

If Massive Bleeding

EGD

Order if:

• Hemodynamic instability

• Massive hematochezia

• Concern brisk UGIB

Medications

Resuscitation

Fluids

• LR 1–2 L IV bolus
  OR

• NS 1–2 L IV bolus

Blood Products

PRBC

• Goal Hgb >7

• Goal Hgb >8 if:

  • CAD

  • ACS

  • Elderly

  • Active shock

Platelets

• If <50,000 with active bleeding

FFP

• If INR >1.5 and bleeding

PCC (Kcentra)

• Warfarin-associated bleeding

Andexanet Alfa

• Factor Xa inhibitor bleeding

Hold Medications

• Aspirin

• Clopidogrel

• Ticagrelor

• Warfarin

• DOACs

• Heparin

• NSAIDs

Discuss restart timing with GI/Cardiology.

Etiology-Specific Treatment

Diverticular Bleed

• Supportive care

• Colonoscopy

• IR embolization if persistent

Ischemic Colitis

• Bowel rest

• IV fluids

• Treat hypotension/shock

• Broad-spectrum antibiotics if moderate-severe

Examples:

• Ceftriaxone 2 g IV daily + Metronidazole 500 mg IV q8h
  OR

• Piperacillin-Tazobactam 4.5 g IV q6h

Infectious Colitis

C. difficile

• Vancomycin 125 mg PO QID

Severe/Fulminant C. diff

• Vancomycin 500 mg PO QID

• Metronidazole 500 mg IV q8h

IBD Flare

After infection excluded:

Ulcerative Colitis

• Methylprednisolone 60 mg IV daily

Crohn's

• Methylprednisolone 40–60 mg IV daily

GI to direct biologics.

Consults

Always

• Gastroenterology

Consider

Interventional Radiology

If:

• CTA positive

• Ongoing bleed

• Poor colonoscopy candidate

General Surgery

If:

• Massive bleeding

• Failed colonoscopy

• Failed embolization

Cardiology

If:

• Recent PCI/stent

• Need antiplatelet recommendations

Colorectal Surgery

If:

• Recurrent diverticular bleeding

• Malignancy

PT/OT

If:

• Falls

• Deconditioning

Nursing Orders

• Admit to telemetry

• NPO initially

• Strict I&O

• Fall precautions

• Monitor stool frequency and color

• Vital signs q4h

Notify physician immediately for:

• SBP <90

• HR >110

• Syncope

• New large-volume hematochezia

• Hgb drop >2 g/dL