Stethopedia | Approach

Approach to

GI Bleeding

Resuscitate first (transfuse in shock, Hb <70 g/L otherwise), start varix therapy if cirrhosis, then localize the source (upper, variceal, lower, small bowel), risk-stratify with Glasgow-Blatchford or Oakland, and scope.

  1. Hematemesis, coffee-ground emesis, melena or hematochezia
  2. Two large-bore IVs; shock index, rectal exam; CBC, INR, urea, creatinine, crossmatch12
  3. Unstable, cirrhosis or antithrombotic?

Unstable: resuscitate, ICU, then EGD or CTA1,3,12

  • Shock (SI >1 or SBP <90): RBC now3,12
  • Hb <70 g/L (<80 if CV disease): transfuse1,2,12
  • Large hematemesis or ↓LOC: intubate7,12
  • Cirrhosis: octreotide, ceftriaxone, EGD ≤12 h7
  • Anticoagulant: hold; warfarin: PCC, not FFP9
  • Cardiac ASA: keep; no vit K, no TXA9,10

→ Hematochezia + shock: EGD if upper possible, else CTA3,12

If stable: where is the source?

CausesCluesWorkupManagement

Upper, nonvariceal

  • Peptic ulcer: NSAIDs, H. pylori
  • Esophagitis, gastritis, Mallory-Weiss
  • Aortoenteric fistula (aortic graft)
  • Melena on exam (LR 25)4
  • Urea:Cr >0.12 (BUN:Cr >30): LR 7.54
  • NSAIDs or aspirin; epigastric pain
  • Blatchford ≤1: outpatient EGD1,5
  • Others: EGD within 24 h1,2
  • Aortic graft: CTA, vascular surgery12
  • Pre-EGD: erythromycin ± IV PPI1,12
  • High-risk ulcer: scope, IV PPI ×3 d1,2
  • PPI BID ×2 wk; H. pylori, retest if neg1,2

Variceal

  • Esophageal varices
  • Gastric varices
  • Portal hypertensive gastropathy
  • Known cirrhosis or heavy alcohol use
  • Ascites, spider angiomas, low platelets
  • EGD within 12 h of presentation7
  • INR, bilirubin, albumin: Child-Pugh
  • Octreotide 2–5 d; ceftriaxone 1 g/d7
  • Band ligation; avoid over-transfusing6,7
  • TIPS ≤72 h: Child C10–13 or B+active7

Lower GI

  • Diverticular bleed (30–65%)12
  • Hemorrhoids, angioectasia, colitis
  • Colorectal cancer; post-polypectomy
  • Painless hematochezia; older adult
  • Clots in stool: not upper (LR 0.05)4
  • Hematochezia + shock: 10–15% upper12
  • Oakland ≤8: outpatient colonoscopy3,8
  • Admitted: colonoscopy after prep3
  • Brisk bleed: CTA, not urgent colo3
  • Most stop on their own
  • Endoscopic clips or coagulation3
  • CTA positive: embolize; surgery last3

Small bowel

  • Angioectasia; Heyde (with AS)
  • Crohn, NSAID ulcers, tumour
  • Meckel diverticulum if young
  • Normal EGD and colonoscopy11
  • Iron deficiency; recurrent melena
  • Second-look EGD or colonoscopy11
  • Capsule endoscopy first line11
  • CT enterography if stricture risk11
  • Deep enteroscopy to treat lesion11
  • Iron; octreotide for angioectasia12

Can't-miss cause Superscripts link to the references below.

References

  1. Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG clinical guideline: upper gastrointestinal and ulcer bleeding. Am J Gastroenterol. 2021;116:899–917. PubMed 33929377
  2. Barkun AN, Almadi M, Kuipers EJ, et al. Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the International Consensus Group. Ann Intern Med. 2019;171:805–822. PubMed 31634917
  3. Sengupta N, Feuerstein JD, Jairath V, et al. Management of patients with acute lower gastrointestinal bleeding: an updated ACG guideline. Am J Gastroenterol. 2023;118:208–231. PubMed 36735555
  4. Srygley FD, Gerardo CJ, Tran T, Fisher DA. Does this patient have a severe upper gastrointestinal bleed? JAMA. 2012;307:1072–1079. PubMed 22416103
  5. Stanley AJ, Laine L, Dalton HR, et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ. 2017;356:i6432. PubMed 28053181
  6. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11–21. PubMed 23281973
  7. de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C; Baveno VII Faculty. Baveno VII – renewing consensus in portal hypertension. J Hepatol. 2022;76:959–974. PubMed 35120736
  8. Oakland K, Jairath V, Uberoi R, et al. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. Lancet Gastroenterol Hepatol. 2017;2:635–643. PubMed 28651935
  9. Abraham NS, Barkun AN, Sauer BG, et al. ACG-CAG clinical practice guideline: management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol. 2022;117:542–558. PubMed 35297395
  10. HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT). Lancet. 2020;395:1927–1936. PubMed 32563378
  11. Gerson LB, Fidler JL, Cave DR, Leighton JA. ACG clinical guideline: diagnosis and management of small bowel bleeding. Am J Gastroenterol. 2015;110:1265–1287. PubMed 26303132
  12. Gay E, Levy N, eds. Upper GI Bleeding; Lower GI Bleeding. In: Department of Medicine Housestaff Manual, 30th ed. 2024:67–68.

For education only; not a substitute for clinical judgment or local protocols. Where sources differ, the flowchart follows the current guideline.

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