Upper gastrointestinal bleeding comes from the esophagus, stomach or duodenum, above the ligament of Treitz. Peptic ulcers are the most common cause, followed by varices, esophagitis and Mallory-Weiss tears.
Key symptoms
- Vomiting blood or coffee-ground material
- Black, tarry stools (melena)
- Lightheadedness, weakness or fainting
- Upper abdominal pain or a history of NSAID or alcohol use
What you find on exam
- Pulse and blood pressure; look for shock and orthostatic changes
- Rectal exam for melena
- Signs of liver disease: jaundice, ascites, spider angiomas
- Abdominal tenderness or rigidity
Tests
- Blood count, type and crossmatch, coagulation tests
- BUN raised out of proportion to creatinine
- Risk score such as Glasgow-Blatchford
- Upper endoscopy within 24 hours
Treatment basics
- Two large-bore IVs, fluids, and blood if hemoglobin is below 7 g/dL
- IV proton pump inhibitor such as pantoprazole
- Suspected varices: octreotide and ceftriaxone
- Endoscopic therapy to stop the bleeding
- Stop NSAIDs and treat H. pylori if present
Red flags
- Low blood pressure, fast pulse or fainting
- Ongoing large-volume vomiting of blood
- Known cirrhosis or varices
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.