CCS Integrated Cases

CCS case: GI bleed with hemodynamic compromise

Clinical Overview and When to Suspect GI Bleed with Hemodynamic Compromise

— Upper GI bleed (UGIB) incidence ~60–100/100,000/yr; mortality 2–10%, higher with rebleeding, age >65, comorbidity

— Lower GI bleed (LGIB) ~20–30/100,000/yr; usually self-limited but diverticular and ischemic causes can crash

— Variceal bleeding mortality remains 15–20% at 6 weeks

— Overt: hematemesis, coffee-ground emesis, melena, hematochezia, bright red blood per rectum

— Covert: syncope, near-syncope, unexplained tachycardia, new anemia with positive FOBT, isolated drop in Hgb in a patient on anticoagulation/NSAIDs

— "Brisk UGIB can present as hematochezia" — ~10–15% of hematochezia is actually upper source with rapid transit

— Two questions in the first 60 seconds: (1) Is the patient hemodynamically unstable? (2) Upper vs lower source likely?

— Stability drives tempo: unstable → resuscitate first, scope second; stable → risk stratify (Glasgow-Blatchford for UGIB)

— Cirrhosis, prior variceal bleed, alcohol use → varices

— NSAIDs, H. pylori, prior PUD → peptic ulcer

— AAA repair with graft → aortoenteric fistula (massive, often "herald" bleed first)

— Retching then hematemesis → Mallory-Weiss

— Painless large-volume hematochezia in elderly → diverticular or angiodysplasia

— Anticoagulants/DOACs/antiplatelets → modifies reversal strategy

CCS pearl: On a CCS case, the moment vitals show SBP <90 or HR >120 with GI bleeding clues, your first three clicks should be two large-bore IVs, type & crossmatch, and IV crystalloid bolus — before you ever click "GI consult" or "EGD."

Definition: Acute GI hemorrhage (upper or lower) accompanied by signs of inadequate perfusion — SBP <90, HR >100, shock index ≥1.0, orthostasis, lactate >2, or end-organ hypoperfusion (AMS, oliguria, cool extremities, troponin leak).

Epidemiology & stakes:

When to suspect on arrival:

Initial framing in the ED (CCS mindset):

High-risk historical clues:

Presentation Patterns and Key History

— Localizes to source proximal to ligament of Treitz

— Bright red = active arterial or variceal; coffee-ground = older blood, gastric acid–oxidized

— Always ask: how many episodes, volume (cups, bowls), and timing

— Black, tarry, sticky, foul — requires ≥50 mL blood and ≥14 hours transit

— Usually UGIB; small bowel or right colon possible with slow transit

— Key distinction: Iron and bismuth cause black stool but NOT tarry/sticky and stool guaiac is negative for iron

— Bright red or maroon blood per rectum

— Usually LGIB but brisk UGIB in ~10–15% — if hemodynamically unstable hematochezia, scope upper first (or NG lavage)

— Lightheadedness, syncope, chest pain, dyspnea → hemodynamic compromise

— Abdominal pain: PUD (epigastric), mesenteric ischemia (out of proportion), AAA (back/flank)

— Weight loss, dysphagia → malignancy

— Prior episodes, prior endoscopies, known varices/ulcers

— NSAIDs, aspirin, clopidogrel, warfarin, DOACs (apixaban, rivaroxaban, dabigatran)

— SSRIs (increase bleed risk via platelet dysfunction)

— Recent antibiotics altering INR in warfarin users

— PPI use (may have been masking ulcer symptoms)

— Alcohol use disorder, hepatitis B/C, known cirrhosis → varices, portal hypertensive gastropathy

— AAA repair → aortoenteric fistula

— Inflammatory bowel disease, radiation history, prior GI surgery

— Recent colonoscopy with polypectomy (post-polypectomy bleed up to 14 days out)

— Cirrhosis + hematemesis = variceal until proven otherwise → octreotide + ceftriaxone early

— AAA graft + GI bleed = aortoenteric fistula → emergent CTA and vascular surgery

— Anticoagulated + spontaneous hematochezia = check INR/anti-Xa, plan reversal

Board pearl: A "herald bleed" — small self-limited GI hemorrhage in a patient with prior aortic graft — precedes catastrophic exsanguination in hours to days. Never discharge; admit and image immediately.

Hematemesis (bright red or coffee-ground):

Melena:

Hematochezia:

Symptom triage questions (CCS history clicks):

Medication history — high yield:

Social and PMH:

Red flag combinations:

Physical Exam Findings and Hemodynamic Assessment

— HR >100 with SBP normal = ~15% blood loss (Class II)

— SBP <90 or orthostatic drop (SBP ↓20, HR ↑20 on standing) = ~30% loss (Class III)

— SBP <90 + AMS + cool/clammy = ≥40% loss (Class IV), peri-arrest

— Shock index (HR/SBP) ≥1.0 predicts need for massive transfusion

— Pallor, diaphoresis, mottling, delayed cap refill, altered mental status

— Cold, clamped extremities = compensated shock; warm/flushed in early sepsis-mimic

— Pale conjunctivae, dry mucosa

— Telangiectasias on lips/tongue → hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu)

— Spider angiomata on face/chest, scleral icterus → cirrhosis

— Tachycardia, narrow pulse pressure, flow murmur

— Listen for new murmur — severe anemia precipitates demand ischemia and CHF

— Distension, ascites, caput medusae → portal hypertension

— Epigastric tenderness → PUD

— Pulsatile mass → AAA

— Peritonitis → perforation (uncommon but catastrophic complication)

— Confirms melena vs hematochezia vs occult blood

— Identifies hemorrhoids, masses, fissures

— Step 3 management: Document rectal exam findings; in a CCS case, click "rectal exam" early — examiners reward this

— Jaundice, palmar erythema, asterixis → decompensated liver disease

— Petechiae, ecchymoses → coagulopathy or thrombocytopenia

— Cool, mottled lower extremities → shock perfusion deficit

CCS pearl: The hemodynamic exam dictates resuscitation tempo. On CCS, reassess vitals q15min during active resuscitation, q1h once stable. Advancing the clock without rechecking vitals after a fluid bolus or transfusion loses points and reflects unsafe practice.

Vital signs first — quantify the shock:

General appearance:

HEENT/neck:

Cardiopulmonary:

Abdomen:

Rectal exam — mandatory:

Skin and extremities:

Diagnostic Workup — Initial Labs and Bedside Studies

— CBC with differential

— BMP (BUN/Cr ratio >30 suggests UGIB from absorbed blood protein)

— LFTs (assess for cirrhosis)

— PT/INR, aPTT

— Type and crossmatch ≥2 units PRBCs (4–6 units if unstable)

— Lactate (perfusion marker)

— Troponin and ECG (demand ischemia risk in elderly/CAD)

— Lipase if abdominal pain

— Blood gas (VBG acceptable) for acid-base, base deficit

— Initial Hgb can be normal in acute hemorrhage — plasma and RBCs lost proportionally; equilibration takes 24–72 h with fluid shifts

— Elevated BUN with normal Cr → digested blood protein, supports UGIB

— MCV: microcytic suggests chronic blood loss; macrocytic suggests alcohol/liver

— Platelets <50k or INR >1.5 in cirrhotic = expected but increases bleeding tempo

— Age >50, known CAD, chest pain, dyspnea, or HR >110

— Look for ischemic changes from demand mismatch — silent NSTEMI is common

— Board pearl: A GI bleed patient with new T-wave inversions or troponin bump has type 2 MI — treat the bleed, hold antiplatelets cautiously, cardiology consult; do NOT cath emergently

— No longer recommended to "rule out" UGIB; coffee grounds confirm but clear aspirate does not exclude (post-pyloric bleeds miss)

— Consider if source localization is unclear before urgent colonoscopy in unstable hematochezia

— Point-of-care Hgb on iSTAT for rapid trending

— POCUS: IVC collapsibility, FAST if trauma overlap, assess for ascites

Step 3 management: Recheck CBC q4–6h during active bleeding, more frequently (q2h) if transfusing or hemodynamically tenuous. Trend the Hgb trajectory, not a single value — a "normal" Hgb of 11 that drops to 8 in 4 hours is an active bleed.

Order set on arrival (first 5 minutes, CCS clicks):

Interpretation pearls:

ECG indications (don't skip):

NG lavage — selective, not routine:

Bedside tools:

Diagnostic Workup — Advanced and Confirmatory Studies

— Timing: within 24 hours of presentation for most UGIB; within 12 hours for variceal bleeding or ongoing hemodynamic instability after resuscitation

— Diagnostic AND therapeutic (clips, thermal, injection, banding)

— Forrest classification of ulcers guides rebleeding risk:

— Ia (spurting), Ib (oozing): high risk, requires intervention

— IIa (visible vessel), IIb (adherent clot): intermediate

— IIc (flat pigmented spot), III (clean base): low risk

— After rapid bowel prep (4–6 L PEG over 3–4 h via NG if needed) within 24 hours of presentation in hemodynamically stabilized patients

— Identifies diverticular bleeding, angiodysplasia, colitis, malignancy, post-polypectomy bleed

— Use when ongoing bleeding (≥0.3 mL/min) and endoscopy unavailable, non-diagnostic, or patient too unstable for prep

— No bowel prep required; rapid; localizes active extravasation

— Key distinction: CTA finds active bleeding; tagged RBC scan (Tc-99m) detects slower bleeds (0.1 mL/min) but is less precise anatomically and slower to obtain

— Both diagnostic and therapeutic (embolization)

— Reserved for massive bleeding with failed endoscopy or as bridge to surgery

— For obscure GI bleeding (negative EGD and colonoscopy) — usually small bowel source (angiodysplasia, NSAID enteropathy, Meckel's, small bowel tumor)

— Outpatient workup in stable patients; not for the acute unstable bleeder

— Young patient with painless LGIB → Meckel's diverticulum with ectopic gastric mucosa

CCS pearl: Click "GI consult, urgent" early — EGD timing is a quality measure. For variceal suspicion, also click "interventional radiology consult on standby" — TIPS may be needed if endoscopic therapy fails. Don't wait until rebleeding to mobilize backup.

Upper endoscopy (EGD) — gold standard for UGIB:

Colonoscopy — for LGIB:

CT angiography:

Mesenteric angiography:

Capsule endoscopy and balloon enteroscopy:

Meckel's scan (Tc-99m pertechnetate):

Risk Stratification and Resuscitation Logic

— Glasgow-Blatchford Score (GBS): Pre-endoscopy; uses BUN, Hgb, SBP, HR, melena, syncope, hepatic/cardiac disease

— GBS = 0–1: very low risk, consider outpatient management

— GBS ≥7: high risk, urgent endoscopy and admission

— Rockall score: post-endoscopy, mortality prediction

— Oakland score: LGIB, score ≤8 may allow outpatient management

— Two large-bore IVs (16–18 gauge) or central access if peripheral fails

— Initial crystalloid bolus: 500–1000 mL NS or LR (avoid over-resuscitation in cirrhotics — raises portal pressure, worsens variceal bleed)

— Transfuse PRBCs to a restrictive threshold of Hgb 7 g/dL (Hgb 8 if active CAD)

— Massive transfusion protocol (1:1:1 PRBC:FFP:platelets) if ongoing hemorrhagic shock or ≥4 units in first hour anticipated

— Warfarin + life-threatening bleed: 4-factor PCC (Kcentra) 25–50 U/kg + IV vitamin K 10 mg

— Dabigatran: idarucizumab 5 g IV

— Apixaban/rivaroxaban: andexanet alfa or 4F-PCC if andexanet unavailable

— Antiplatelets: platelet transfusion only if active life-threatening bleed and need for procedure (controversial outside neurosurgery)

— Intubate for massive hematemesis, AMS (encephalopathy in cirrhotic), inability to protect airway

— Aspiration is a leading cause of death in variceal bleeders

Step 3 management: Restrictive transfusion (Hgb 7) reduces mortality and rebleeding vs liberal strategy in UGIB (Villanueva NEJM 2013). Exception: active ACS, symptomatic anemia → target Hgb 8.

Risk scores (know one for upper, one for lower):

Resuscitation principles — CCS sequence:

Reversal of anticoagulation:

Airway:

Foley catheter: Monitor UOP target ≥0.5 mL/kg/h as perfusion surrogate

Pharmacotherapy — First-Line Drug Regimen

— Pantoprazole 80 mg IV bolus, then 8 mg/hr infusion × 72 hours (or 40 mg IV BID)

— Rationale: stabilizes clot, reduces rebleeding in high-risk ulcers, may downgrade lesion

— Continue oral PPI BID × 2 weeks, then daily × 6–8 weeks for ulcer

— Octreotide 50 mcg IV bolus, then 50 mcg/hr infusion × 3–5 days — reduces splanchnic blood flow

— Ceftriaxone 1 g IV daily × 7 days — SBP prophylaxis; reduces mortality and rebleeding (cirrhotics have high rate of bacterial translocation)

— Lactulose for hepatic encephalopathy prevention/treatment if AMS

— Avoid beta-blockers acutely; restart nonselective BB (nadolol, propranolol, carvedilol) after acute bleed resolved for secondary prevention

— Erythromycin 250 mg IV 30–90 min pre-endoscopy — promotes gastric emptying, improves visualization in active bleeding

— Not recommended for routine GI bleed (HALT-IT trial 2020 showed no mortality benefit, increased VTE)

— Hold antiplatelets and anticoagulants based on bleeding severity and indication

— No specific pre-procedural drug therapy

— Test all peptic ulcers; treat if positive

— Triple therapy (PPI + amoxicillin + clarithromycin) only if local clarithromycin resistance <15%; otherwise bismuth quadruple therapy (PPI + bismuth + tetracycline + metronidazole) × 14 days

— Restart within 7 days if high thrombotic risk (mechanical valve, recent VTE, AF with CHA2DS2-VASc ≥4) balanced against rebleeding risk

— Bridge with prophylactic LMWH if needed

Board pearl: In a cirrhotic with hematemesis, the three drugs that save lives are octreotide, ceftriaxone, and a PPI — start all three empirically before EGD confirms varices. Forgetting ceftriaxone is a classic Step 3 distractor.

All UGIB suspected (before endoscopy):

Suspected variceal bleeding (cirrhosis, known varices):

Prokinetics before EGD (selective):

Tranexamic acid (TXA):

For LGIB:

H. pylori treatment (post-EGD if ulcer confirmed):

Anticoagulation resumption (after bleed control):

Procedures and Endoscopic/Surgical Management

— Dual therapy (epinephrine injection + thermal coagulation or hemoclips) for Forrest Ia/Ib/IIa

— Hemospray (TC-325) as rescue

— Over-the-scope clips for large/recurrent bleeds

— Second-look endoscopy not routine; only if rebleed suspected

— Endoscopic variceal band ligation (EVL) — first line for esophageal varices

— Sclerotherapy if EVL not technically feasible

— Gastric varices: cyanoacrylate glue injection (especially IGV1/GOV2)

— Balloon tamponade (Sengstaken-Blakemore/Minnesota tube): temporizing bridge for uncontrolled hemorrhage, max 24 h, requires intubation

— TIPS (transjugular intrahepatic portosystemic shunt): rescue for failed endoscopic therapy; early/preemptive TIPS within 72 h in Child-Pugh B with active bleeding or Child C (≤13) reduces rebleeding and mortality

— Clips, banding, thermal coagulation, epinephrine injection for diverticular or post-polypectomy bleeds

— Argon plasma coagulation for angiodysplasias and radiation proctitis

— Mesenteric angiography with superselective embolization (microcoils, gel foam) for ongoing bleeding when endoscopy fails or is delayed

— Risk: bowel ischemia (~1–4%)

— Indications: hemodynamic instability despite >6 units PRBC, failed endoscopic and IR therapy, perforation, aortoenteric fistula

— Procedures: oversewing ulcer + vagotomy/pyloroplasty (rare today), partial gastrectomy, segmental colectomy for localized LGIB, subtotal colectomy if source unidentified

CCS pearl: The order "Consult GI, emergent" is required within the first hour for unstable UGIB. For variceal bleeding with cirrhosis, also consult hepatology/transplant and IR — TIPS candidacy assessment in parallel saves time if endoscopy fails.

Endoscopic hemostasis — UGIB peptic ulcer:

Variceal bleeding:

LGIB endoscopic therapy:

Interventional radiology:

Surgery — last resort:

Aortoenteric fistula: Emergent vascular surgery — graft excision, extra-anatomic bypass

Special Populations — Elderly and Renal/Hepatic Impairment

— Higher baseline rate of NSAID ulcers, angiodysplasia, diverticular bleeding, colon cancer

— Reduced physiologic reserve — shock develops with smaller blood loss; beta-blockers mask tachycardia

— Transfusion threshold may shift to Hgb 8 for known CAD or symptomatic anemia

— Higher risk of demand ischemia, delirium, aspiration, hospital-acquired complications

— Polypharmacy: review NSAIDs, antiplatelets, anticoagulants, SSRIs at every visit

— Uremic platelet dysfunction → bleeding diathesis even with normal platelet count

— Treatment: DDAVP 0.3 mcg/kg IV, cryoprecipitate, conjugated estrogens; correct anemia with EPO long-term

— Avoid magnesium-based bowel preps; use PEG

— Adjust PPI dosing minimally needed; pantoprazole preferred (hepatic metabolism)

— Key distinction: ESRD patients have higher rates of upper GI angiodysplasia — recurrent obscure bleeds warrant capsule endoscopy

— Coagulopathy is rebalanced, not simply "bleeding tendency" — INR does not reliably predict bleeding

— Avoid over-transfusion of FFP (raises portal pressure)

— Platelet target ≥50k for procedures; consider thrombopoietin receptor agonists (avatrombopag) electively

— Albumin 1.5 g/kg day 1, 1 g/kg day 3 if large-volume paracentesis or SBP — also useful in HRS-AKI

— Lactulose titrated to 2–3 soft stools/day for encephalopathy

— Screen for HCC and stratify MELD for transplant candidacy

— Restrictive transfusion essential; avoid volume overload — give PRBCs slowly, consider furosemide between units

— Hold ACEi/ARB during active bleed if hypotensive; restart at discharge

Step 3 management: In cirrhotic UGIB, do NOT routinely correct INR with FFP. It increases portal pressure, worsens bleeding, and adds volume. Use vitamin K if vitamin K deficiency suspected; otherwise focus on octreotide, ceftriaxone, and EVL.

Elderly (≥65):

Chronic kidney disease:

Cirrhosis / hepatic impairment:

Heart failure:

Special Populations — Pregnancy, Pediatrics, and Other Subgroups

— GI bleeding rare; consider Mallory-Weiss from hyperemesis, PUD, hemorrhoids

— HELLP syndrome can present with hepatic hemorrhage/subcapsular hematoma — RUQ pain, elevated LFTs, low platelets, hemolysis; delivery is definitive treatment

— Endoscopy is safe in pregnancy when indicated; left lateral decubitus position, minimize sedation, GI + OB co-management

— Avoid misoprostol (uterotonic), tetracyclines, bismuth; PPIs (pantoprazole, lansoprazole) are safe

— Maternal hemodynamics protect the fetus — resuscitate the mother aggressively

— Neonates: swallowed maternal blood, vitamin K deficiency bleeding, NEC, malrotation with volvulus

— Toddlers: Meckel's diverticulum (painless LGIB, "rule of 2s"), intussusception (currant jelly stool, sausage mass)

— School age: PUD, esophagitis, varices (portal vein thrombosis), Henoch-Schönlein purpura

— Adolescents: IBD, Mallory-Weiss

— Weight-based fluid resuscitation: 20 mL/kg isotonic bolus, repeat as needed; PRBC 10 mL/kg

— CMV colitis, Kaposi sarcoma, lymphoma, idiopathic ulcers

— Lower threshold for endoscopy and biopsy

— Recurrent epistaxis + telangiectasias + GI bleeding + family history

— Long-term: iron repletion, IV bevacizumab for refractory bleeding

— High GI bleed rate (~20% per year) from acquired von Willebrand disease + angiodysplasia

— Manage with reduced anticoagulation intensity, octreotide for prevention

Board pearl: Painless, large-volume hematochezia in a 2-year-old = Meckel's diverticulum until proven otherwise. Order a Meckel's scan (Tc-99m pertechnetate). Surgical resection is definitive.

Pregnancy:

Pediatrics:

Immunocompromised / HIV:

Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu):

LVAD patients:

Complications and Adverse Outcomes

— Acute kidney injury from prolonged hypoperfusion — monitor UOP, Cr q12–24h

— Hepatic ischemia ("shock liver") — transaminases into thousands, recover with perfusion

— Acute coronary syndrome (type 2 MI from demand-supply mismatch)

— UGIB: 10–20% within 72 h; higher in Forrest Ia/Ib, large ulcers >2 cm, posterior duodenal bulb (gastroduodenal artery)

— Variceal: 30–40% within 6 weeks without secondary prophylaxis

— Signs: recurrent hematemesis/melena, tachycardia, drop in Hgb >2 g/dL, transfusion requirement after stabilization

— Hematemesis + AMS = high aspiration risk; low threshold for intubation

— TRALI, TACO (volume overload, especially elderly/HF), febrile non-hemolytic reactions, hemolysis, hyperkalemia (massive transfusion), hypocalcemia (citrate), coagulopathy (dilutional)

— Monitor ionized calcium, potassium during massive transfusion

— EGD: perforation (<0.1%), aspiration, sedation hypotension

— TIPS: hepatic encephalopathy (20–30%), heart failure exacerbation, shunt stenosis

— Embolization: bowel ischemia, contrast nephropathy

— VTE — chemoprophylaxis often held during active bleed; restart 48 h after bleed control if stable; use mechanical prophylaxis in interim

— C. difficile from PPI + antibiotics

— Delirium, deconditioning, pressure ulcers in elderly

— Age >65, hemodynamic instability at presentation, comorbidities (cirrhosis, CKD, CAD), rebleeding, in-hospital onset, transfusion >4 units

Step 3 management: Restart mechanical VTE prophylaxis (SCDs) on arrival; restart pharmacologic VTE prophylaxis (LMWH or heparin) within 48–72 h of bleed control. Do not abandon prophylaxis entirely — VTE is a common preventable death in GI bleed admissions.

Hemorrhagic shock and multi-organ dysfunction:

Rebleeding:

Aspiration pneumonia/pneumonitis:

Transfusion complications:

Procedure complications:

Hospital-acquired complications:

Mortality predictors:

When to Escalate — ICU, Consult, and Disposition

— Hemodynamic instability despite initial resuscitation (SBP <90, HR >110, lactate >2)

— Active hematemesis requiring intubation

— Massive transfusion protocol activation

— Variceal bleeding with cirrhosis Child B/C

— Suspected aortoenteric fistula

— Severe comorbidity (active ACS, decompensated HF, encephalopathy)

— Need for vasopressors or continuous octreotide infusion in unstable patient

— Stable after resuscitation but high rebleed risk (GBS ≥12, Rockall ≥5)

— Recent endoscopic intervention for high-risk lesion

— Ongoing transfusion needs without instability

— Stabilized, low–moderate risk, post-endoscopy with low-risk lesion (Forrest IIc/III)

— GBS 0–1 with reliable follow-up, no comorbidities, normal vitals, normal Hgb — consider for ED discharge with GI follow-up in 24–48 h

— Oakland score ≤8 for LGIB

— GI: urgent for EGD/colonoscopy — within 12–24 h

— Surgery: standby for massive bleeding, perforation, aortoenteric fistula

— Interventional radiology: if angiography/embolization or TIPS may be needed

— Hepatology/transplant: cirrhotic variceal bleed — MELD assessment, transplant candidacy

— Cardiology: type 2 MI, troponin elevation, ACS overlap

— Hematology: complex coagulopathy, hereditary bleeding disorders

— If facility lacks 24/7 endoscopy, IR embolization, or surgical backup → transfer to tertiary center with hemodynamic stabilization first

— Document EMTALA-compliant transfer; accepting physician name, transport mode

CCS pearl: On CCS, "transfer to ICU" should occur when the patient is persistently unstable despite 2 L crystalloid + 2 units PRBC, OR has variceal bleed with Child B/C cirrhosis. Document the criteria in your reasoning to avoid losing safety points.

ICU admission criteria:

Step-down/telemetry:

Floor admission:

Outpatient management:

Consults to mobilize (CCS clicks):

Transfer considerations:

Key Differentials — Same-Category Causes (GI Sources)

— Peptic ulcer disease (PUD): ~40% of UGIB; risk factors H. pylori, NSAIDs, stress, ZES

— Esophagogastric varices: cirrhosis, portal hypertension; large-volume hematemesis, painless

— Mallory-Weiss tear: retching followed by hematemesis; usually self-limited

— Erosive esophagitis/gastritis/duodenitis: NSAIDs, alcohol, severe reflux

— Dieulafoy lesion: dilated submucosal artery, recurrent unexplained UGIB, often gastric fundus

— Gastric antral vascular ectasia (GAVE, "watermelon stomach"): chronic occult bleeding, iron-deficiency anemia, associated with cirrhosis, scleroderma

— Malignancy: gastric or esophageal cancer; weight loss, dysphagia, early satiety

— Cameron lesions: linear erosions in hiatal hernia sac

— Aortoenteric fistula: prior AAA repair, herald bleed → exsanguination

— Angiodysplasia (most common small bowel source in elderly)

— NSAID enteropathy

— Meckel's diverticulum (pediatric/young adult)

— Small bowel tumor (GIST, lymphoma, carcinoid, adenocarcinoma)

— Crohn's disease

— Diverticular bleeding: most common LGIB, painless, large-volume, often right-sided; usually self-limited

— Angiodysplasia: elderly, right colon, painless, can be massive or chronic

— Ischemic colitis: watershed areas (splenic flexure, rectosigmoid), pain + bloody diarrhea, post-hypotension, AAA repair

— Hemorrhoids/anal fissure: bright red blood on tissue/toilet; rarely cause shock

— Colorectal cancer: occult or overt, weight loss, change in bowel habits, iron-deficiency anemia

— IBD (UC, Crohn's): bloody diarrhea, abdominal pain, tenesmus

— Infectious colitis: EHEC O157:H7, Shigella, Campylobacter, C. difficile

— Post-polypectomy bleeding: up to 14 days after procedure

— Radiation proctitis: prior pelvic radiation, chronic intermittent bleeding

Key distinction: Diverticular bleed = painless large-volume hematochezia. Ischemic colitis = painful hematochezia with risk factors for hypoperfusion (recent hypotension, vascular disease, cocaine). Don't conflate.

Upper GI sources:

Mid GI (small bowel, ligament of Treitz to ileocecal valve):

Lower GI sources:

Key Differentials — Other-Category Mimics

— Hemoptysis: bright red, frothy, mixed with sputum, alkaline pH, coughed up

— Hematemesis: darker, acidic pH, may contain food, vomited

— History clue: preceding cough vs nausea/retching

— Mimics UGIB; posterior nosebleeds can produce hematemesis/melena

— Anterior rhinoscopy + nasopharyngoscopy resolves

— Dental procedures, tonsillar bleed, oral cavity lesions

— Inspect mouth, pharynx

— Triad: RUQ pain + jaundice + UGIB

— Causes: recent hepatobiliary procedure (PTC, biopsy), trauma, tumor, hepatic artery aneurysm

— Diagnose with CTA or angiography

— Bleeding from pancreatic duct, usually pseudoaneurysm of splanchnic artery in chronic pancreatitis

— Intermittent UGIB with epigastric pain

— Severe thrombocytopenia (ITP, TTP, HIT, drug-induced)

— Coagulopathy (warfarin overdose, DOAC accumulation in CKD, DIC, hemophilia)

— Vasculitis (HSP/IgA vasculitis with GI involvement, polyarteritis nodosa)

— Iron supplements, bismuth (Pepto-Bismol) → black stool, NOT melena (guaiac negative for iron, positive for bismuth)

— Beets, food coloring, blackberries → red/black stool color change without bleeding

— Critically ill patients on vasopressors develop stress ulcers — prevent with PPI prophylaxis in mechanical ventilation >48 h or coagulopathy

— Ruptured AAA presenting with syncope and GI symptoms

— Mesenteric ischemia: pain out of proportion, lactic acidosis, late bloody stools

Board pearl: A patient on iron supplements with "black stool" but negative guaiac and normal Hgb has pseudomelena. Don't admit them for endoscopy on the basis of stool color alone — confirm with occult blood testing and CBC trend.

Hemoptysis vs hematemesis:

Epistaxis with swallowed blood:

Oropharyngeal bleeding:

Hemobilia:

Hemosuccus pancreaticus:

Bleeding diathesis / systemic causes:

Drug- and substance-induced:

Sepsis with GI mucosal stress lesions:

Aorto-enteric fistula vs vascular catastrophes:

Secondary Prevention and Discharge Medications

— Continue PPI BID × 2 weeks post-bleed, then daily × 6–8 weeks for ulcer healing

— Test and treat H. pylori — eradication confirmed with urea breath test or stool antigen ≥4 weeks after therapy, off PPI ≥2 weeks

— Discontinue NSAIDs if possible; if essential, use lowest dose + concurrent PPI + COX-2 selective (celecoxib)

— Aspirin for cardiovascular indication: resume within 1–7 days post-bleed for secondary CV prevention (mortality benefit outweighs rebleeding risk)

— Nonselective beta-blocker (nadolol, propranolol, or carvedilol preferred) — titrate to HR 55–60 or maximum tolerated

— Serial EVL every 2–4 weeks until variceal eradication, then surveillance EGD q6–12 months

— Continue PPI short-term post-banding; long-term only if other indication

— Avoid NSAIDs (worsen renal function, increase variceal bleed risk)

— Consider TIPS for refractory rebleeding

— High-fiber diet, hydration

— Avoid NSAIDs and aspirin where possible

— Recurrence ~25% at 4 years; elective colectomy not routinely recommended after first episode

— Reassess risk-benefit; LAA closure (Watchman) for AF patients with high bleed risk

— Switch warfarin to DOAC if appropriate (apixaban has lowest GI bleed risk among DOACs)

— Coordinate restart timing with primary indication's specialist

— Oral ferrous sulfate 325 mg daily or every other day (better tolerated, equal absorption) for 3–6 months

— IV iron (ferric carboxymaltose, iron sucrose) if intolerant, malabsorption, or severe deficiency

— Alcohol cessation (varices, gastritis)

— Smoking cessation (delays ulcer healing)

— Weight loss, reflux precautions

Step 3 management: For a patient on aspirin for secondary CV prevention who bleeds, resume aspirin within 1–7 days after hemostasis — withholding it doubles cardiovascular mortality. This is a frequently tested Step 3 trade-off.

PUD secondary prevention:

Variceal bleed secondary prevention (combined approach):

Diverticular bleed prevention:

Anticoagulation management:

Anemia repletion:

Lifestyle:

Follow-Up, Monitoring, and Counseling

— Hemodynamic stability ≥24 h

— Stable Hgb on two consecutive checks ≥6 h apart

— Tolerating oral intake and oral medications

— No ongoing transfusion requirement

— Safe home environment, medication reconciliation complete

— Primary care follow-up within 1–2 weeks — vitals, medication review, anemia symptoms, refill PPI

— GI follow-up within 2–4 weeks for ulcer/varices/polypectomy review; sooner if symptoms recur

— Repeat CBC at 2 weeks to confirm Hgb trajectory; iron studies at 4–6 weeks

— H. pylori eradication confirmation ≥4 weeks after therapy completion (urea breath or stool antigen), off PPI ≥2 weeks

— Repeat EGD at 8–12 weeks for gastric ulcers (rule out malignancy with biopsy if not done initially); not routinely needed for duodenal ulcers unless symptomatic

— Serial EVL every 2–4 weeks until eradication

— Surveillance EGD every 6–12 months

— Liver function, MELD score every 3–6 months; HCC screening (US + AFP q6 months) in cirrhotic

— Any LGIB in patient >40 without clear benign source warrants colonoscopy

— If colonoscopy normal during acute bleed but high suspicion persists, consider repeat in 6–12 months with adequate prep

— Warning signs to return: black/tarry stools, vomiting blood, lightheadedness, syncope, chest pain

— Medication list — emphasize avoiding NSAIDs/aspirin unless prescribed

— Alcohol cessation resources (AA, naltrexone, acamprosate)

— Smoking cessation

— Diet: balanced, high-fiber for diverticular disease; small frequent meals if reflux

— Screen for alcohol use disorder (AUDIT-C), refer to addiction services

— Address depression/anxiety post-hospitalization

CCS pearl: On the final CCS screen, document "return precautions reviewed, follow-up scheduled with PCP in 1 week and GI in 2 weeks, H. pylori eradication test scheduled at 4 weeks" — this hits transition-of-care safety points.

Discharge readiness criteria:

Post-discharge cadence:

Variceal surveillance:

Colon cancer screening:

Patient counseling:

Mental health and substance use:

Ethical, Legal, and Patient Safety Considerations

— Standard of care; document risks (TRALI, TACO, infection, hemolysis), benefits, alternatives

— Jehovah's Witness: refuse PRBC, FFP, platelets, WBC; many accept albumin, cell salvage, erythropoietin, IV iron, factor concentrates (vary by individual)

— Document specific products refused with patient signature; in emergencies with unconscious patient, refer to advance directive or surrogate; if none, transfuse per best interests doctrine

— Minors: courts may override parental refusal for life-saving transfusion

— Implied consent applies in life-threatening emergency when patient incapacitated and no surrogate available

— Document medical decision-making and attempts to contact family

— Active GI bleed with hypotension or hepatic encephalopathy compromises capacity

— Use surrogate decision-maker hierarchy per state law

— ED to ICU, ICU to floor, hospital to home are leading sources of medication errors

— Use structured handoff (SBAR or I-PASS); explicit anticoagulation plan, PPI duration, H. pylori testing pending

— Reconcile medications at admission, transfer, and discharge — anticoagulant resumption is a top error

— Anticoagulant resumption decisions require shared decision-making; document thrombotic vs bleeding risk weighing

— Avoid PPI as default lifelong without indication — long-term risks include C. difficile, osteoporosis, hypomagnesemia, B12 deficiency, CKD

— Massive transfusion events typically require root cause analysis

— In-hospital UGIB is a quality measure; trends tracked by CMS

— Endoscopy timing <24 h is a quality metric

— Address code status and goals of care early in critically ill or end-stage cirrhotic patients

— Palliative care consult for refractory variceal bleeding in non-transplant candidates

Board pearl: A conscious Jehovah's Witness with massive UGIB refusing blood — respect the refusal, escalate to bloodless medicine protocols (IV iron, EPO, TXA, cell salvage, factor concentrates). Court orders to force transfusion in competent adults will not succeed and are unethical.

Informed consent for transfusion:

Emergency consent:

Capacity assessment:

Transitions of care — high-risk handoffs:

Medication safety:

Reporting and quality:

Advance directives:

High-Yield Associations and Rapid-Fire Facts

Step 3 management: Memorize these triggers — they appear as one-line stems demanding a single best next step. Pattern recognition beats deliberation on test day.

BUN/Cr ratio >30 with melena → UGIB (digested blood protein)

Forrest Ia/Ib ulcer → endoscopic dual therapy + IV PPI infusion

Cirrhotic UGIB → octreotide + ceftriaxone + PPI + EVL

Restrictive transfusion threshold Hgb 7 (Hgb 8 if active CAD) — lower rebleeding and mortality

Massive transfusion ratio 1:1:1 PRBC:FFP:platelets

Glasgow-Blatchford 0–1 → outpatient candidate

Painless large-volume hematochezia, elderly → diverticular bleed or angiodysplasia

Painful hematochezia + recent hypotension → ischemic colitis (splenic flexure)

Painless LGIB in 2-year-old → Meckel's diverticulum, Tc-99m scan

Prior AAA repair + GI bleed → aortoenteric fistula, emergent CTA

Retching → hematemesis → Mallory-Weiss tear

Watermelon stomach (GAVE) → cirrhosis, scleroderma, chronic IDA

Dieulafoy lesion → recurrent unexplained UGIB, dilated submucosal artery, gastric fundus

Hemobilia triad → RUQ pain + jaundice + UGIB (post-hepatobiliary procedure)

TIPS complications → hepatic encephalopathy, heart failure

Idarucizumab reverses dabigatran; andexanet alfa reverses apixaban/rivaroxaban; 4F-PCC + vitamin K reverses warfarin

DDAVP for uremic platelet dysfunction

Apixaban has lowest GI bleed risk among DOACs

Carvedilol preferred nonselective BB for variceal prophylaxis

Repeat EGD at 8–12 weeks for gastric ulcers to rule out malignancy; duodenal ulcers don't need routine repeat

H. pylori eradication confirmation with urea breath/stool antigen ≥4 weeks post-therapy, off PPI ≥2 weeks

HALT-IT trial → TXA does NOT reduce mortality in GI bleed, increases VTE; not routinely used

Aspirin for secondary CV prevention → restart within 1–7 days post-bleed

Early TIPS within 72 h for Child B with active bleeding or Child C ≤13 — reduces rebleeding and mortality

Erythromycin 250 mg IV pre-EGD improves visualization in active bleeding

Avoid FFP in cirrhotic UGIB — raises portal pressure

Board Question Stem Patterns

— "55-year-old man with alcoholic cirrhosis presents with hematemesis. BP 88/52, HR 118. Next step?"

— Answer: IV access, crystalloid, octreotide + ceftriaxone + IV PPI, urgent EGD within 12 h. Don't pick "FFP" or "TIPS first."

— "Stable patient post-UGIB, Hgb 6.8 g/dL, no CAD. Transfuse to what target?"

— Answer: Hgb 7 g/dL (one unit at a time, reassess)

— "Patient on warfarin, INR 4.5, active GI bleed. Reversal?"

— Answer: 4F-PCC + IV vitamin K 10 mg. Not FFP (slower, larger volume).

— "Hematochezia + SBP 80 + HR 130. Most likely source?"

— Answer: Consider upper GI source (~15% of massive hematochezia); EGD first, then colonoscopy after stabilization.

— "Prior AAA graft repair, presents with self-limited UGIB. Next step?"

— Answer: Admit + emergent CTA, do not discharge — herald bleed.

— "Recent CABG with hypotensive episode, now bloody diarrhea and crampy abdominal pain. Diagnosis?"

— Answer: Ischemic colitis, supportive care, colonoscopy.

— "2-year-old with painless large-volume rectal bleeding. Next test?"

— Answer: Tc-99m pertechnetate scan (Meckel's scan).

— "Treated H. pylori 4 weeks ago. Confirm eradication how?"

— Answer: Urea breath test or stool antigen, off PPI ≥2 weeks. Not serology (stays positive).

— "PUD bleed in patient on aspirin for prior MI. Long-term aspirin plan?"

— Answer: Resume aspirin within 1–7 days + PPI for gastroprotection.

— "Conscious adult Jehovah's Witness refuses blood for UGIB. Best action?"

— Answer: Respect refusal, use bloodless protocols (IV iron, EPO, TXA, factor concentrates).

— "Gastric ulcer on EGD with hemostasis. Follow-up?"

— Answer: Repeat EGD in 8–12 weeks to confirm healing and rule out malignancy.

Board pearl: When two answer choices are both "reasonable" interventions, choose the one that addresses hemodynamics first, then the one with mortality evidence (restrictive transfusion, ceftriaxone in cirrhotics, early TIPS in Child B/C).

Pattern 1 — Cirrhotic with hematemesis:

Pattern 2 — Restrictive transfusion:

Pattern 3 — Anticoagulant reversal:

Pattern 4 — Brisk hematochezia:

Pattern 5 — Aortoenteric fistula:

Pattern 6 — Painful hematochezia after hypotension:

Pattern 7 — Meckel's:

Pattern 8 — H. pylori follow-up:

Pattern 9 — Aspirin resumption:

Pattern 10 — Jehovah's Witness:

Pattern 11 — Gastric ulcer surveillance:

One-Line Recap

The unstable GI bleed patient is resuscitated first, scoped second, and risk-stratified for source-specific therapy — with restrictive transfusion (Hgb 7), early IV PPI for UGIB, octreotide plus ceftriaxone for suspected varices, urgent endoscopy within 12–24 hours, and a deliberate, mortality-aware plan for anticoagulant reversal and resumption.

CCS pearl: The winning CCS sequence is vitals → IV access → labs/T&C → fluids → consults → empiric drugs → endoscopy → reassess at q15min/q1h/q4h intervals → restrictive transfusion → ICU vs floor disposition → discharge with structured follow-up. Skipping a reassessment loses safety points; ordering FFP for INR correction in a cirrhotic loses clinical-accuracy points.

Hemodynamics first: Two large-bore IVs, crystalloid 500–1000 mL, type & cross, transfuse PRBC to Hgb 7 (Hgb 8 if CAD), activate MTP for refractory shock — vitals q15min until stable, then q1h.

Empiric pharmacotherapy by suspected source: All UGIB → IV pantoprazole 80 mg bolus then 8 mg/hr; cirrhotic UGIB → ADD octreotide 50 mcg/hr + ceftriaxone 1 g IV daily × 7 days. Don't forget erythromycin 250 mg IV pre-EGD if active bleeding.

Definitive control: EGD within 24 h (12 h for variceal/unstable); colonoscopy within 24 h for LGIB after prep; CTA/embolization or surgery for refractory cases; early TIPS within 72 h for Child B active bleeders or Child C ≤13.

Secondary prevention and handoff: Test/treat H. pylori with eradication confirmation at 4 weeks; repeat EGD at 8–12 weeks for gastric ulcers; nonselective beta-blocker + serial EVL for varices; restart aspirin within 1–7 days when indicated; PCP follow-up at 1–2 weeks, GI at 2–4 weeks, recheck Hgb at 2 weeks, iron repletion for 3–6 months.