Gastrointestinal

Upper GI bleeding: CCS-style management and risk stratification

Clinical Overview and When to Suspect Upper GI Bleeding

— Peptic ulcer disease (PUD): ~40–50% — most common overall

— Gastritis/erosive disease: ~15%

— Esophageal/gastric varices: ~10–20% (dominant cause in cirrhosis)

— Mallory-Weiss tear: ~5–10% (post-retching, alcoholic, pregnancy hyperemesis)

— Erosive esophagitis, Dieulafoy lesion, malignancy, AVMs, aortoenteric fistula

— Hematemesis (bright red or coffee-ground) — virtually pathognomonic

— Melena — black, tarry, foul stool; implies ≥50 mL blood and ≥14 hours transit; usually UGI but can be small bowel/right colon

— Hematochezia + hemodynamic instability — think brisk UGIB (~10–15% of "lower GI" bleeds are actually upper)

— Unexplained iron-deficiency anemia, syncope, or BUN/Cr ratio >30 in adult

— NSAIDs, aspirin, anticoagulants, DOACs, dual antiplatelet therapy

— Known cirrhosis, varices, prior variceal bleed

— H. pylori, prior PUD, GERD, smoking, alcohol use

— AAA repair → think aortoenteric fistula; aortic stenosis → Heyde syndrome (acquired vWD + AVMs)

— Retching/vomiting prior to hematemesis → Mallory-Weiss

— Chronic kidney disease, LVAD → angiodysplasia

CCS pearl: On the CCS interface, the moment you see hematemesis or melena with tachycardia/hypotension, your first three orders before any history-taking should be two large-bore IVs, type & crossmatch, and IV fluids (NS or LR bolus) — location: ED. Diagnostics and consults follow only after initial resuscitation is initiated. Failure to resuscitate first is the most common CCS scoring penalty on this topic.

Definition: bleeding proximal to the ligament of Treitz — esophagus, stomach, duodenum. Annual US incidence ~60–100/100,000 adults; mortality 2–10%, higher in cirrhotics and elderly.

Etiologic snapshot (memorize prevalence):

When to suspect UGIB:

High-risk historical clues (Step 3 hot buttons):

Presentation Patterns and Key History

— Hematemesis: bright red = active arterial/variceal; coffee-ground = older, acid-denatured blood (gastric)

— Melena: PUD until proven otherwise; ask about NSAID/ASA use

— Hematochezia with shock: massive UGIB — varices, ulcer with visible vessel, aortoenteric fistula

— Syncope or near-syncope without overt bleeding: consider occult UGIB; check rectal exam and Hgb

— Dyspepsia → sudden hematemesis: classic PUD

— Retching → hematemesis: Mallory-Weiss (usually self-limited)

— Painless large-volume hematemesis in cirrhotic: variceal bleed

— NSAIDs, aspirin, clopidogrel, ticagrelor

— Warfarin (INR), DOACs (apixaban, rivaroxaban, dabigatran — last dose timing)

— SSRIs (mild bleed risk via platelets), bisphosphonates (esophagitis), steroids

— Iron, bismuth — false melena (no occult blood positivity)

— Cirrhosis/portal HTN → empiric octreotide + ceftriaxone before EGD

— CAD with recent stent → balancing rebleeding vs stent thrombosis

— AAA repair → CT angio before EGD if stable

— CKD/dialysis → uremic platelet dysfunction, consider DDAVP

— Prior bariatric surgery → marginal ulcer at gastrojejunal anastomosis

Step 3 management: A 68-year-old on apixaban with melena — your history must capture time of last DOAC dose, CrCl, and indication for anticoagulation because this dictates reversal strategy (andexanet alfa vs 4F-PCC vs hold). Documenting indication (AFib CHA₂DS₂-VASc vs mechanical valve) drives the bridging plan after the bleed is controlled.

Board pearl: BUN/Cr ratio >30:1 in absence of renal failure strongly suggests UGIB — blood protein digested and absorbed in small bowel raises BUN disproportionately.

Cardinal symptoms — pattern recognition:

Medication history (always ask, always document):

Comorbidity history that changes management:

Social: alcohol (varices, gastritis, Mallory-Weiss), tobacco (PUD, malignancy), H. pylori exposure, recent NSAID for arthritis flare

Physical Exam Findings and Hemodynamic Assessment

— Resting tachycardia (HR >100): ~15% blood volume loss

— Orthostatic hypotension (SBP drop ≥20 or HR rise ≥20 on standing): ~15–30% loss

— Supine hypotension (SBP <90): ≥30–40% loss — class III/IV shock

— Narrow pulse pressure is an early sign before frank hypotension

— Pallor, cool/clammy extremities, delayed cap refill

— Altered mental status — hypoperfusion or hepatic encephalopathy in cirrhotic

— Spider angiomata, palmar erythema, gynecomastia, caput medusae

— Jaundice, ascites (shifting dullness, fluid wave), splenomegaly

— Asterixis, fetor hepaticus

— → If present, treat as variceal bleed empirically until EGD

— Epigastric tenderness → PUD

— Peritoneal signs (rigidity, rebound) → perforated ulcer — surgical emergency, NOT endoscopy first

— Pulsatile mass → AAA; prior graft + UGIB → aortoenteric fistula until proven otherwise

— Succussion splash → gastric outlet obstruction (chronic PUD)

— Confirm melena vs hematochezia vs bright red blood

— Rule out hemorrhoids/fissure as confounder

— Document stool color — guides triage

— Telangiectasias on lips/tongue → Osler-Weber-Rendu (HHT)

— Perioral pigmentation → Peutz-Jeghers

— Acanthosis nigricans → gastric malignancy

CCS pearl: Recheck vitals every 15 minutes during active resuscitation on the CCS clock. A patient who was HR 110/BP 100/60 at presentation and is now HR 130/BP 80/50 after 2 L crystalloid needs blood products NOW and emergent GI consult — advance the simulated clock only after these orders are placed.

Key distinction: Orthostatics are useful early but unreliable in patients on beta-blockers (blunted HR response) — common in cirrhotics on nadolol for variceal prophylaxis. Trust supine BP and lactate instead.

Vital signs first — define shock class:

General exam:

Stigmata of chronic liver disease (changes everything):

Abdominal exam:

Rectal exam (mandatory):

Skin/mucosal clues:

Diagnostic Workup — Initial Labs and Imaging

— CBC: baseline Hgb may be falsely normal in acute bleed (no time for hemodilution); recheck q4–6h

— BMP: BUN/Cr ratio >30 supports UGIB; check K⁺ (transfusion, vomiting)

— LFTs + albumin: screen for cirrhosis; low albumin/elevated INR = synthetic dysfunction

— PT/INR, PTT: coagulopathy, warfarin effect

— Type & crossmatch ≥2 units pRBC (4–6 units if unstable or cirrhotic)

— Lactate: marker of tissue hypoperfusion; >4 → aggressive resuscitation

— Troponin + ECG: demand ischemia in elderly/CAD patients with anemia

— Lipase: if epigastric pain

— Pregnancy test: women of reproductive age

— Hgb <7 g/dL in hemodynamically stable patients (target 7–9)

— Hgb <8 g/dL if active CAD, ACS, or ongoing massive bleeding

— Restrictive strategy reduces mortality vs liberal (Villanueva NEJM 2013)

— In suspected variceal bleed, avoid over-transfusion — increases portal pressure and rebleeding

— Platelets if <50,000 with active bleed

— FFP if INR >2 (variable, less effective than PCC for warfarin)

— 4F-PCC for warfarin reversal with active bleed + vitamin K 10 mg IV

— Avoid correcting INR to normal in cirrhotics (rebalanced hemostasis)

— CXR if perforation suspected (free air under diaphragm)

— CT angiography if brisk bleeding and EGD unrevealing/not feasible; mandatory if aortoenteric fistula suspected

— Avoid barium studies — obscure subsequent endoscopy

Board pearl: A patient with melena and Hgb 14 on arrival is not reassuring — equilibration takes 24–72 hours. The trajectory matters more than the snapshot; recheck CBC and act on hemodynamics.

Step 3 management: Order PPI (pantoprazole 80 mg IV bolus then 8 mg/hr infusion) empirically before EGD — reduces high-risk endoscopic stigmata and rebleeding even before the source is known.

Immediate labs (order all simultaneously on CCS):

Transfusion thresholds (restrictive strategy — high yield):

Coagulopathy correction:

Imaging:

Diagnostic Workup — Advanced and Confirmatory Studies

— Timing: within 24 hours of presentation for all UGIB; within 12 hours for variceal bleed or hemodynamic instability after resuscitation

— Diagnostic AND therapeutic (clips, thermal coagulation, banding, sclerotherapy, epinephrine injection)

— Identifies source in ~90% of cases

— Pre-EGD: erythromycin 250 mg IV 30–90 min before — prokinetic, improves visualization (especially variceal bleeds)

— Ia: spurting arterial — 90% rebleed risk

— Ib: oozing — 10–20%

— IIa: non-bleeding visible vessel — 50%

— IIb: adherent clot — 25–30%

— IIc: flat pigmented spot — 7–10%

— III: clean base — <3% (suitable for early discharge)

— Forrest Ia–IIb → endoscopic therapy + IV PPI infusion 72h

— Forrest IIc–III → no endoscopic therapy needed; oral PPI, early discharge

— CT angiography: detects bleeding ≥0.3 mL/min; localizes source for IR

— Tagged RBC scintigraphy: detects ≥0.1 mL/min, intermittent bleeding

— Repeat EGD (push enteroscopy)

— Capsule endoscopy for suspected small bowel source (after UGIB ruled out)

— Mesenteric angiography: diagnostic + therapeutic embolization

— Suspected aortoenteric fistula: CT angio FIRST, then EGD; do not delay surgery

— Variceal hemorrhage: EGD with band ligation; sclerotherapy if gastric varices use cyanoacrylate glue

CCS pearl: Order EGD as soon as the patient is hemodynamically stable — on CCS, this means after at least 2 L crystalloid, blood transfusion initiated if Hgb <7, and consult to GI is placed. Do not advance the clock past 12–24 hours without an EGD result for active UGIB.

Key distinction: NG lavage is no longer routine — does not improve outcomes, may delay EGD. Erythromycin pre-EGD is preferred.

Upper endoscopy (EGD) — gold standard:

Forrest classification (PUD — must know):

If EGD is non-diagnostic and bleeding continues:

Special scenarios:

Risk Stratification — Glasgow-Blatchford and Rockall Scores

— Variables: BUN, Hgb, SBP, HR, melena, syncope, hepatic disease, cardiac failure

— Score 0–1: very low risk → consider outpatient management with prompt EGD

— Score ≥7: high risk for intervention, admission required

— GBS is the single best validated tool for ED disposition

— Variables: age, shock, comorbidity, endoscopic diagnosis, stigmata of recent hemorrhage

— Score 0–2: low risk; ≥5: high mortality

— Albumin <3, INR >1.5, Mental status altered, SBP ≤90, age >65 — each 1 point

— ≥2 points: high mortality, ICU admission

— GBS 0–1, hemodynamically stable, reliable follow-up: outpatient EGD within 24h, oral PPI, no transfusion needed

— GBS ≥1 or any high-risk feature: admit to monitored bed

— Hemodynamic instability, ongoing bleeding, cirrhosis, severe comorbidity: ICU

— IV access ×2 large bore (16–18g)

— IV PPI infusion or high-dose bolus

— Transfuse to Hgb 7 (8 if CAD)

— If cirrhotic: octreotide 50 mcg bolus then 50 mcg/hr × 3–5 days + ceftriaxone 1g IV daily × 7 days (prophylaxis for SBP/bacteremia — reduces mortality)

— Hold antihypertensives, diuretics, anticoagulants

— NPO

Step 3 management: A 35-year-old with one episode of coffee-ground emesis after binge drinking, HR 78, BP 128/76, Hgb 14, BUN 12, no syncope, no comorbidities → GBS = 0 → outpatient EGD within 24h is appropriate; no admission required. Knowing this saves a hospital bed and is a frequent Step 3 disposition vignette.

Board pearl: In cirrhotic UGIB, ceftriaxone reduces mortality more than any other single intervention besides band ligation — never forget the antibiotic.

Glasgow-Blatchford Score (GBS) — pre-endoscopy, drives disposition:

Rockall Score — post-endoscopy, predicts mortality and rebleeding:

AIMS65 (alternative, simpler):

Disposition decision tree:

Empiric pre-EGD management bundle:

Pharmacotherapy — First-Line Drug Regimens

— Pantoprazole 80 mg IV bolus, then 8 mg/hr continuous infusion × 72 hours for high-risk endoscopic stigmata (Forrest Ia–IIb) post-endoscopic hemostasis

— Alternative: 40 mg IV q12h intermittent (non-inferior in some studies)

— Transition to oral PPI BID × 2 weeks, then daily × 6–8 weeks for ulcer healing

— Mechanism: stabilizes clot by maintaining gastric pH >6 (pepsin inactivation, platelet aggregation)

— Octreotide: 50 mcg IV bolus, then 50 mcg/hr × 3–5 days

· Splanchnic vasoconstriction → ↓ portal pressure

· Start empirically in any cirrhotic with UGIB before EGD

— Terlipressin (preferred globally; FDA-approved 2022 for hepatorenal syndrome, available for varices)

— Vasopressin + nitroglycerin: older, more side effects

— Ceftriaxone 1 g IV daily × 7 days (preferred — covers SBP organisms, resistance pattern)

— Alternative: ciprofloxacin if low local resistance

— Indication: ALL cirrhotic patients with UGIB regardless of ascites

— Erythromycin 250 mg IV 30–90 min before EGD — clears gastric blood for visualization

— Test (urea breath test, stool antigen, or biopsy at EGD)

— Treat with quadruple therapy: PPI + bismuth + tetracycline + metronidazole × 14 days (preferred 1st line per ACG 2017)

— Or PPI + amoxicillin + clarithromycin × 14 days if clarithromycin resistance <15%

— Confirm eradication ≥4 weeks after treatment (urea breath test or stool antigen) — Step 3 favorite

— Warfarin: vitamin K 10 mg IV + 4F-PCC (preferred) or FFP

— Dabigatran: idarucizumab 5 g IV

— Factor Xa inhibitors (apixaban, rivaroxaban): andexanet alfa or 4F-PCC

— Antiplatelet agents: platelet transfusion controversial; consider in life-threatening bleed only

CCS pearl: Order PPI infusion immediately at presentation — do not wait for EGD findings. On CCS, the sequence is IVF → blood → PPI → octreotide (if cirrhotic) → ceftriaxone → GI consult → EGD.

Proton pump inhibitor (PPI) — cornerstone for non-variceal UGIB:

Vasoactive agents for variceal bleeding:

Antibiotics in cirrhotic UGIB (mortality benefit):

Prokinetic pre-EGD:

H. pylori eradication (after PUD-related bleed):

Anticoagulation reversal:

Procedural and Endoscopic Management

— Combination therapy is standard: epinephrine injection (1:10,000) PLUS a second modality (thermal coagulation, mechanical clips, or hemostatic powder)

— Epinephrine alone is inadequate (high rebleed)

— Hemoclips preferred for visible vessels and Mallory-Weiss tears

— Bipolar electrocoagulation or heater probe for ulcers with active bleeding

— Over-the-scope clips (OTSC) for refractory/recurrent ulcer bleeds

— Hemospray/TC-325 as rescue or temporizing therapy

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

— Cyanoacrylate (glue) injection — first line for gastric (fundal) varices

— Sclerotherapy reserved if banding fails (higher complication rate)

— Repeat EGD with different modality — first salvage

— Transjugular intrahepatic portosystemic shunt (TIPS) — for refractory variceal bleeding

· Indications: failed endoscopic + medical therapy, Child-Pugh B/C with active bleed

· Contraindications: severe heart failure, severe pulmonary HTN, uncontrolled sepsis, polycystic liver

· Complication: hepatic encephalopathy (~25%)

— IR angiographic embolization — for non-variceal refractory bleed (PUD, Dieulafoy, malignancy)

— Balloon tamponade (Sengstaken-Blakemore/Minnesota tube) — temporizing bridge to TIPS only; max 24h; risk of esophageal necrosis/aspiration; intubate first

— Perforated ulcer (always surgery, NOT endoscopy)

— Aortoenteric fistula

— Failed TIPS/embolization

— Hemodynamic instability with ongoing transfusion requirement >6 units/24h

— Procedures: oversewing of bleeding vessel, vagotomy + antrectomy (rare)

Step 3 management: Cirrhotic with active variceal bleed, failed banding, hemodynamically unstable → place Minnesota tube as bridge while activating TIPS team. Do not delay TIPS for repeat EGD if first endoscopic attempt failed in unstable patient.

Board pearl: Aortoenteric fistula = prior aortic graft + herald GI bleed → CT angio → emergent vascular surgery. Endoscopy is often non-diagnostic and delays definitive repair.

Endoscopic hemostasis for non-variceal UGIB (PUD):

Endoscopic management of variceal bleeding:

Failure of endoscopic therapy (~10–15%):

Surgery (last resort, rare in PPI era):

Special Populations — Elderly and Renal/Hepatic Impairment

— Higher mortality (8–13% vs 2–4%)

— NSAIDs and antiplatelet use are dominant drivers

— Atypical presentation: syncope, fatigue, confusion without overt hematemesis

— Lower threshold for ICU admission and transfusion (Hgb <8 if CAD)

— Polypharmacy review: stop NSAIDs, consider PPI co-prescription if aspirin must continue

— Bleeding risk scores (HAS-BLED) for atrial fibrillation revision after bleed

— Uremic platelet dysfunction: consider DDAVP 0.3 mcg/kg IV for active bleed (releases vWF/FVIII from endothelium)

— Conjugated estrogens (slower onset, sustained effect)

— Avoid magnesium-containing antacids

— Adjust PPI? — most PPIs do not require renal adjustment, but use lowest effective dose long-term (CKD progression concern)

— Angiodysplasia more common in CKD/AS (Heyde syndrome — aortic stenosis acquires vWF deficiency)

— Always assume variceal bleed until EGD proves otherwise — start octreotide + ceftriaxone empirically

— Avoid over-resuscitation: target Hgb 7–8, SBP ~100 — over-transfusion increases portal pressure and rebleeding

— Avoid lactated Ringer's if severe hepatic dysfunction (impaired lactate clearance — controversial, NS often preferred)

— Coagulopathy is rebalanced — do NOT automatically correct INR with FFP unless active life-threatening bleed; risk of volume overload and worsened portal HTN

— Lactulose for hepatic encephalopathy prophylaxis after bleed (large protein load in gut)

— Child-Pugh and MELD scores predict mortality

— Long-term: non-selective beta-blocker (nadolol/propranolol/carvedilol) + serial EVL for secondary prophylaxis

— TIPS as bridge to transplant in recurrent variceal bleeding

Step 3 management: Cirrhotic discharged after first variceal bleed — start carvedilol 6.25 mg daily (preferred over propranolol per AASLD 2023) AND schedule EVL every 2–4 weeks until varices eradicated, then surveillance EGD every 6–12 months. Both pharmacologic and endoscopic prophylaxis combined > either alone.

Key distinction: In cirrhotic UGIB, the antibiotic (ceftriaxone) saves more lives than the octreotide. Don't skip it.

Elderly (>65):

Chronic kidney disease/ESRD:

Cirrhosis/hepatic impairment:

Special Populations — Pregnancy and Pediatrics

— Most common cause: Mallory-Weiss tear from hyperemesis gravidarum

— Also: reflux esophagitis (relaxed LES from progesterone), PUD (less common in pregnancy due to estrogen-mediated mucosal protection)

— Imaging: EGD is safe in pregnancy at any trimester — preferred when indicated; minimize sedation, use propofol or low-dose meperidine, left lateral position in 2nd/3rd trimester to avoid IVC compression

— Avoid: misoprostol (abortifacient), bismuth (teratogen)

— Safe medications: sucralfate (Category B), ranitidine (historical), PPIs (pantoprazole Cat B, others Cat C — generally considered safe)

— Avoid CT with contrast if possible; MRI without gadolinium acceptable

— H. pylori treatment deferred until postpartum (clarithromycin Cat C, tetracycline contraindicated)

— Neonates: swallowed maternal blood (Apt test differentiates), vitamin K deficiency bleeding, NEC

— Infants/toddlers: esophagitis, gastritis, Mallory-Weiss, foreign body, caustic ingestion

— Older children: PUD (often H. pylori), varices (biliary atresia, portal vein thrombosis), Dieulafoy, vascular malformations

— Always consider non-accidental trauma in unexplained pediatric GI bleed

— Resuscitation: 20 mL/kg NS bolus, repeat ×2, then blood 10 mL/kg

— Avoid NSAIDs after bleed

— Pre-conception variceal screening recommended

— Variceal bleeding in pregnancy: octreotide is Category B (use cautiously); avoid vasopressin (uterine contraction)

— EVL safe; TIPS relatively contraindicated (radiation, fetal risk)

— Multidisciplinary: hepatology, MFM, GI

Board pearl: Apt test (alkali denaturation) distinguishes fetal hemoglobin (resistant, stays pink) from maternal hemoglobin (denatures, turns yellow-brown) in neonatal hematemesis/melena — classic Step 3 neonatal vignette where mother had cracked nipples while breastfeeding.

Step 3 management: A 28-year-old G2P1 at 30 weeks with hematemesis after severe vomiting — likely Mallory-Weiss; obtain CBC, type & screen, and proceed with EGD if bleeding persists or hemodynamically significant. Most resolve spontaneously with antiemetics, IV PPI, and hydration.

Pregnancy:

Pediatric UGIB:

Pregnancy + cirrhosis (rare but high-stakes):

Complications and Adverse Outcomes

— Hypovolemic shock — most immediate threat; multiorgan dysfunction if delayed resuscitation

— Rebleeding — 10–20% in non-variceal, 30–40% in variceal within 6 weeks

· Highest risk in first 72 hours

· Predictors: Forrest Ia–IIa, age >65, comorbidities, large ulcer (>2 cm), posterior duodenal location (gastroduodenal artery)

— Type 2 MI (demand ischemia) — anemia + tachycardia in CAD; check troponin, ECG

— Decompensated heart failure from over-resuscitation

— Stroke if antiplatelet/anticoagulant held in patient with high thrombotic risk (mechanical valve, recent stent)

— TRALI (acute lung injury, <6h post-transfusion)

— TACO (volume overload — especially elderly, cirrhotic, CKD)

— Citrate toxicity (hypocalcemia) with massive transfusion → check ionized Ca, replace

— Hypothermia, coagulopathy, hyperkalemia — "lethal triad" in massive transfusion

— Perforation (~0.5%), aspiration pneumonia, sedation complications

— Post-banding ulcer (varices) — bleeding 5–10 days later

— Post-TIPS hepatic encephalopathy (~25%) and stent stenosis

— Spontaneous bacterial peritonitis (SBP) — UGIB increases risk 5-fold (hence ceftriaxone prophylaxis)

— Hepatorenal syndrome — precipitated by hypovolemia, sepsis

— Hepatic encephalopathy — large gut protein load → lactulose prophylaxis

— Hepatic decompensation, death

— Iron deficiency anemia — replete oral or IV iron

— Recurrent PUD if H. pylori not eradicated or NSAIDs continued

— Psychiatric: anxiety, fear of recurrence

CCS pearl: After endoscopic hemostasis, the next 72 hours are critical — continue PPI infusion, NPO × 24h, monitor Hgb q6–8h, vitals q4h, and recheck for signs of rebleeding (hematemesis, melena, hypotension, tachycardia, Hgb drop >2 g/dL). Rebleeding mandates repeat EGD before considering surgery/IR.

Board pearl: Posterior duodenal ulcer = gastroduodenal artery erosion → torrential bleed, highest rebleed and mortality rate. Often requires angiographic embolization.

Hemorrhagic complications:

Cardiovascular complications:

Transfusion-related:

Endoscopy-related:

Cirrhosis-specific:

Long-term:

When to Escalate Care — ICU, Consults, and Triage

— Hemodynamic instability despite resuscitation (SBP <90, HR >120, lactate >4)

— Active hematemesis or large-volume melena ongoing

— Hgb <7 with ongoing bleeding or transfusion requirement

— Cirrhosis Child-Pugh C with UGIB

— AIMS65 ≥2 or Rockall ≥5

— Altered mental status (encephalopathy, shock, intoxication)

— Need for intubation (airway protection in massive hematemesis or before emergent EGD in obtunded patient)

— Mechanical ventilation, vasopressors, massive transfusion protocol

— Moderate-risk GBS (2–6) with stable vitals

— Successful endoscopic hemostasis with Forrest IIa–IIb

— Cirrhotic with variceal bleed s/p banding, stable

— Gastroenterology — first call for all UGIB requiring admission

— Interventional radiology — if EGD fails or aortoenteric fistula

— General/vascular surgery — perforation, aortoenteric fistula, refractory bleed

— Hepatology — cirrhotic with variceal bleed, TIPS evaluation, transplant listing

— Cardiology — if balancing antiplatelet hold with recent stent

— Hematology — if complex coagulopathy, suspected vWD/Heyde

— Intubate before EGD if: massive hematemesis, altered mental status, hepatic encephalopathy, hemodynamic instability, inability to protect airway

— Aspiration is leading cause of peri-procedural mortality

— GBS 0–1 + reliable follow-up + transportation → discharge with outpatient EGD within 24h

— All others → admit

Step 3 management: Hemodynamic instability after 2 units pRBC and 2 L crystalloid = mass transfusion protocol activation (1:1:1 ratio pRBC:FFP:platelets), ICU transfer, GI/IR/surgery all consulted simultaneously, and bedside EGD or IR embolization within the hour. On CCS, parallel orders save the patient — don't sequence them.

Key distinction: GI bleeding patients almost never need surgery first in the PPI/endoscopy era — but perforation and aortoenteric fistula are the exceptions where surgery precedes endoscopy.

ICU admission criteria:

Step-down/monitored bed:

Consults — order early on CCS:

Airway management:

Disposition from ED:

Key Differentials — Other Upper GI Sources

— Duodenal > gastric in frequency

— Risk factors: H. pylori (90% of duodenal, 70% gastric), NSAIDs, smoking, stress (ICU patients), Zollinger-Ellison (multiple, refractory ulcers, diarrhea, gastrin >1000)

— Posterior duodenal ulcer → gastroduodenal artery

— Lesser curvature gastric ulcer → left gastric artery

— Always biopsy gastric ulcers to rule out malignancy; repeat EGD in 8–12 weeks to confirm healing

— Portal hypertension (cirrhosis, portal vein thrombosis, schistosomiasis)

— Large volume painless hematemesis, often hemodynamically dramatic

— Treatment: octreotide + ceftriaxone + EVL; TIPS if refractory

— Longitudinal mucosal tear at GE junction from retching

— History: vomiting → hematemesis (key sequence)

— Most resolve spontaneously; endoscopic clip if persistent

— NSAIDs, alcohol, stress, bisphosphonates

— Usually low-volume bleeding; PPI mainstay

— Aberrant submucosal artery (often gastric fundus)

— Recurrent, massive, painless bleeding with normal-appearing mucosa

— Diagnosis often elusive; treat with clip or thermal coagulation

— Elderly, CKD, aortic stenosis (Heyde syndrome — acquired vWD type 2A)

— Recurrent obscure GI bleeding

— Argon plasma coagulation; AVR cures Heyde

— Full-thickness rupture from forceful vomiting

— Mackler triad: vomiting, chest pain, subcutaneous emphysema

— Surgical emergency, not UGIB workup pathway

— Gastric adenocarcinoma, lymphoma, GIST, esophageal cancer

— Weight loss, dysphagia, early satiety; chronic anemia

— Biopsy at EGD

Board pearl: Hematemesis after vomiting/retching = Mallory-Weiss (mucosal tear, bleeding); chest pain + crepitus after vomiting = Boerhaave (transmural rupture, mediastinitis). Different problems, same trigger — don't confuse them on the test.

Peptic ulcer disease (40–50%):

Esophageal/gastric varices (10–20%):

Mallory-Weiss tear (5–10%):

Erosive gastritis/esophagitis:

Dieulafoy lesion:

Angiodysplasia/AVM:

Boerhaave syndrome (perforation, NOT bleeding per se):

Upper GI malignancy:

Key Differentials — Mimics from Other Categories

— 10–15% of "hematochezia" patients have brisk UGIB

— Workup: NG aspirate (low sensitivity), early EGD before colonoscopy if hemodynamically unstable

— Lower GI sources: diverticulosis, angiodysplasia, ischemic colitis, IBD, hemorrhoids, malignancy

— Hemoptysis: bright red, frothy, alkaline pH, mixed with sputum, history of cough/lung disease

— Hematemesis: dark/bright red, acidic pH, mixed with food, history of nausea/abdominal pain

— Patient may swallow blood from hemoptysis → confusion

— Posterior nasal bleed can be swallowed → coffee-ground emesis or melena

— Examine nose and oropharynx in every UGIB workup

— Iron supplements, bismuth (Pepto-Bismol), black licorice, blueberries, activated charcoal

— Fecal occult blood test will be negative in pseudo-melena (key distinguishing feature)

— Red food coloring, beets, red wine, cherry-flavored drinks

— Gastroccult positive in true blood

— Bronchiectasis, TB, lung cancer, AVM

— Anticoagulant overdose, severe thrombocytopenia, DIC, hemophilia

— Treat the coagulopathy AND search for source

— Caustic ingestion (alkali/acid) — esophageal/gastric burns, bleeding; do NOT induce vomiting, urgent EGD within 24h

— Foreign body (button battery, sharp object) — pediatric especially

— Self-inflicted; suspicion when bleeding doesn't match physiology

Step 3 management: Patient with hematochezia, HR 130, BP 85/50, Hgb dropping → do EGD first to rule out brisk UGIB before colonoscopy. The instability + hematochezia combo is a known Step 3 trap; the answer is upper endoscopy, not lower.

Key distinction: Iron and bismuth turn stool black but FOBT is negative — this is the diagnostic clue separating pseudo-melena from true melena.

Lower GI bleeding presenting as hematochezia + UGIB-like instability:

Hemoptysis vs hematemesis:

Epistaxis/oropharyngeal bleeding swallowed:

Pseudo-melena (no actual bleeding):

Pseudo-hematemesis:

Hemoptysis with massive aspiration mimicking GI:

Coagulopathy without structural lesion:

Factitious or accidental ingestion:

Munchausen syndrome / factitious bleeding:

Secondary Prevention and Discharge Medications

— PPI: oral pantoprazole/omeprazole 40 mg BID × 2 weeks, then daily × 6–8 weeks for ulcer healing

— H. pylori testing and treatment — quadruple therapy if positive; confirm eradication ≥4 weeks after treatment with urea breath test or stool antigen

— Repeat EGD at 8–12 weeks for gastric ulcers to confirm healing and rule out malignancy (duodenal ulcers do not require routine repeat EGD)

— Stop NSAIDs permanently if possible; if must continue (e.g., severe arthritis), use lowest dose + PPI co-therapy or switch to COX-2 selective (celecoxib) + PPI

— Aspirin for secondary cardiovascular prevention: resume within 1–7 days after hemostasis (do not stop indefinitely — net mortality worse)

— Non-selective beta-blocker: carvedilol 6.25 mg daily (preferred AASLD 2023) or nadolol/propranolol titrated to HR 55–60

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

— Avoid NSAIDs (renal, bleeding risk)

— No alcohol, nutrition optimization, vaccinate against HAV/HBV/pneumococcus/influenza

— Hepatology follow-up, transplant evaluation if appropriate (MELD ≥15)

— Aspirin for secondary prevention: resume within 1–7 days

— DAPT after PCI: resume aspirin ASAP, P2Y12 inhibitor as soon as hemostasis secure (often within 3–5 days); shorten DAPT duration if possible

— Warfarin/DOAC for AFib: resume in 7–14 days; weigh CHA₂DS₂-VASc vs HAS-BLED

— Mechanical valve: bridge with heparin earlier (high thrombotic risk)

— Oral ferrous sulfate 325 mg daily or every other day (better absorbed)

— IV iron (ferric carboxymaltose, iron sucrose) if severe anemia, intolerance, or malabsorption

Step 3 management: Patient post-PUD bleed on aspirin for prior MI — continue aspirin (or resume within 7 days) with daily PPI indefinitely. Stopping aspirin doubles cardiovascular mortality; the PPI mitigates rebleeding risk.

Board pearl: Always retest for H. pylori eradication after treatment — eradication failure is common (~20%) and a frequent Step 3 follow-up question.

Post-PUD bleed (non-variceal):

Post-variceal bleed:

Anticoagulation/antiplatelet resumption:

Iron repletion:

Follow-Up, Monitoring, and Counseling

— 24–72 hours: primary care or GI phone check-in; reinforce red flags

— 2 weeks: clinic visit; review H. pylori results, medication adherence, symptom resolution

— 4–8 weeks: confirm H. pylori eradication with urea breath test or stool antigen (off PPI ≥2 weeks)

— 8–12 weeks: repeat EGD for gastric ulcers to confirm healing and rule out malignancy

— 3–6 months: reassess NSAID/aspirin need, iron stores (ferritin, CBC)

— 2 weeks: hepatology follow-up; titrate beta-blocker

— 2–4 weeks: repeat EGD for next banding session

— Serial EVL every 2–4 weeks until variceal eradication

— After eradication: surveillance EGD every 6–12 months

— MELD monitoring for transplant listing

— CBC at 2 weeks and as needed for symptoms (fatigue, dyspnea)

— Iron studies if anemia persists

— LFTs, INR, MELD in cirrhotics

— Reassess medications at each visit; minimize anticoagulant/antiplatelet burden

— NSAID avoidance — including OTC ibuprofen, naproxen; review every medication and supplement

— Smoking cessation — counseling + pharmacotherapy (varenicline, NRT, bupropion)

— Alcohol cessation — especially in cirrhotics; AA, naltrexone, acamprosate

— Diet: no specific restrictions for PUD; low-sodium for cirrhotics with ascites

— Red flags to return to ED: hematemesis, melena, hematochezia, syncope, lightheadedness, chest pain, severe abdominal pain

— Medication adherence: PPI before breakfast, beta-blocker daily, antibiotics complete course

— Cirrhotics: HAV, HBV, pneumococcal (PCV20 or PCV15+PPSV23), influenza annually, COVID

CCS pearl: On CCS, after stabilization and EGD, schedule outpatient follow-up explicitly ("appointment with PCP in 2 weeks," "GI follow-up in 4 weeks for repeat EGD," "urea breath test in 4 weeks") — failure to arrange transitions of care is a documented scoring deduction.

Board pearl: Confirm H. pylori eradication off PPI for ≥2 weeks and off antibiotics for ≥4 weeks to avoid false negatives.

Post-discharge timeline (PUD bleed):

Post-discharge timeline (variceal bleed):

Monitoring parameters:

Counseling (high-yield):

Vaccination updates:

Ethical, Legal, and Patient Safety Considerations

— Standard consent for blood products; document risks (TRALI, TACO, infection ~1:2,000,000 HIV/HCV)

— Jehovah's Witness patients: respect refusal of blood; document in advance directive; offer bloodless medicine alternatives (IV iron, erythropoietin, tranexamic acid, cell saver, hemostatic agents, tolerating lower Hgb 5–6)

— Pediatric Jehovah's Witness: parental refusal can be overridden by court order if life-threatening (state intervention via child protective services)

— Emergency exception: implied consent if patient unable to consent and surrogate unavailable

— Intoxicated patient refusing EGD or admission: assess capacity sober if safe to wait; if life-threatening, treat under emergency doctrine

— Hepatic encephalopathy impairs capacity — involve surrogate decision-maker

— Suspected non-accidental trauma in pediatric GI bleed → child protective services

— Elder abuse if suspicious presentation in vulnerable adult → adult protective services

— Gunshot/stab wounds causing UGIB → law enforcement reporting

— Medication reconciliation at admission and discharge — high-risk medications (anticoagulants, NSAIDs, antiplatelets) must be reviewed

— Anticoagulation resumption plan must be explicit and communicated to outpatient provider — failure to clarify causes thrombotic events or rebleeding

— Closed-loop communication with primary care: written discharge summary within 24–48h, F/U appointment scheduled before discharge, medication list reconciled

— Read-back verification of verbal orders during massive transfusion / emergent EGD

— Time-out before EGD to confirm patient, procedure, consent, allergies

— Reducing unnecessary admissions: GBS 0–1 patients can be safely discharged with outpatient EGD (CMS, joint commission metrics)

— Avoiding low-value transfusions (restrictive strategy reduces costs and improves outcomes)

— Procedural perforation, missed lesion on first EGD → honest disclosure per AMA ethics

— End-stage cirrhosis with recurrent variceal bleed: discuss goals of care, palliative options, transplant candidacy

Step 3 management: A Jehovah's Witness with Hgb 4 from PUD bleed refuses transfusion — document capacity, honor refusal, optimize with IV iron + EPO + tranexamic acid + early endoscopic hemostasis, and consult ethics if uncertain. Forced transfusion in a capacitated adult is battery.

Informed consent for transfusion:

Capacity assessment:

Mandatory reporting:

Patient safety / transitions of care (Step 3 emphasis):

Quality and value-based care:

Disclosure of complications:

Advance directives:

High-Yield Associations and Rapid-Fire Clinical Facts

Board pearl: If the stem mentions a patient with a prosthetic aortic graft and any GI bleed, the answer is aortoenteric fistula until ruled out — CT angio, not EGD, is the first step.

Cirrhosis + UGIB → variceal until proven otherwise → octreotide + ceftriaxone + EVL

Prior AAA repair + UGIB → aortoenteric fistula → CT angio → emergency surgery

Aortic stenosis + recurrent GI bleed → Heyde syndrome (acquired vWD + angiodysplasia) → AVR cures

Vomiting → hematemesis → Mallory-Weiss tear

Vomiting → chest pain + subcutaneous emphysema → Boerhaave (NOT bleeding focus)

Posterior duodenal ulcer → gastroduodenal artery → torrential bleed

Lesser curvature gastric ulcer → left gastric artery

BUN/Cr >30:1 without renal failure → UGIB (digested protein load)

Melena requires ≥50 mL blood and ≥14 hours transit

Forrest Ia (spurting) → 90% rebleed without therapy

Forrest III (clean base) → <3% rebleed, can discharge

Glasgow-Blatchford 0–1 → safe outpatient management

AIMS65 ≥2 → high mortality, ICU

Ceftriaxone in cirrhotic UGIB → mortality benefit

Erythromycin 250 mg IV pre-EGD → prokinetic, improves visualization

Restrictive transfusion (Hgb <7) → better outcomes than liberal

PPI infusion post-endoscopic hemostasis × 72h for Forrest Ia–IIb

H. pylori quadruple therapy = PPI + bismuth + tetracycline + metronidazole × 14d

Confirm H. pylori eradication ≥4 weeks post-treatment, off PPI ≥2 weeks

Gastric ulcer → biopsy + repeat EGD at 8–12 weeks (rule out malignancy)

Duodenal ulcer → no routine repeat EGD needed

Zollinger-Ellison → multiple refractory ulcers, diarrhea, gastrin >1000, secretin stim test +

Dieulafoy → fundic, massive recurrent painless bleed, normal mucosa

Watermelon stomach (GAVE) → cirrhosis, scleroderma; APC treatment

NSAID + steroid → 15× ulcer risk

SSRIs → mild bleed risk (platelet serotonin depletion)

TIPS contraindication → severe heart failure, severe pulmonary HTN, polycystic liver

TIPS complication → hepatic encephalopathy in 25%

Sengstaken-Blakemore → bridge to TIPS only, max 24h, intubate first

Apt test → fetal vs maternal Hgb in neonatal hematemesis

Aspirin post-PUD bleed → resume within 1–7 days + PPI indefinitely

Carvedilol → preferred non-selective beta-blocker for variceal prophylaxis (AASLD 2023)

Board Question Stem Patterns

— "55M with epigastric pain, NSAID use, presents with melena, Hgb 8, BUN 45, Cr 1.0, HR 105, BP 110/70."

— Answer pathway: IV access ×2 → IVF → PPI infusion → type & cross → EGD within 24h → Forrest classification → endoscopic therapy if high-risk → H. pylori testing → 8 weeks PPI → confirm eradication

— "60M with cirrhosis presents with massive hematemesis, BP 80/50, HR 130."

— Answer pathway: Resuscitate (target Hgb 7) → octreotide + ceftriaxone empirically → urgent EGD within 12h → EVL → discharge on carvedilol + serial EVL

— "70M s/p AAA repair 3 years ago presents with small hematemesis followed by massive bleeding 6 hours later."

— Answer: CT angiography of abdomen/pelvis (NOT EGD first) → vascular surgery consult → emergent graft revision

— "78F with severe aortic stenosis has recurrent obscure GI bleeding, normal EGD, normal colonoscopy."

— Answer: Capsule endoscopy → angiodysplasia → consider AVR as definitive treatment (corrects acquired vWD)

— "25F at 12 weeks pregnancy with hyperemesis, then hematemesis after retching."

— Answer: Supportive care, antiemetics, IV PPI; EGD only if persistent or severe

— "35M, single episode coffee-ground emesis after alcohol binge, HR 78, BP 130/80, Hgb 14, BUN 14, no comorbidities."

— Answer: Glasgow-Blatchford 0 → outpatient management with EGD within 24h

— "Patient completed quadruple therapy 3 weeks ago, asks about confirming cure."

— Answer: Wait at least 4 weeks after completing antibiotics and 2 weeks off PPI → urea breath test or stool antigen

— "75M on apixaban with melena, last dose 4 hours ago, Hgb 7."

— Answer: Hold apixaban, transfuse, consider andexanet alfa or 4F-PCC, urgent EGD

— "Capacitated adult JW refuses transfusion despite life-threatening bleed."

— Answer: Honor refusal, optimize with non-blood alternatives (IV iron, EPO, TXA, endoscopy)

— "Neonate with coffee-ground emesis, mother has cracked nipples breastfeeding."

— Answer: Apt test to differentiate maternal from fetal blood

Step 3 management: Stems often hinge on disposition, prophylaxis, follow-up cadence, or medication resumption — not just diagnosis. Always read the question for what's being asked: next best step, most likely diagnosis, or long-term management.

Stem 1 — Classic PUD bleed:

Stem 2 — Variceal bleed in cirrhotic:

Stem 3 — Aortoenteric fistula:

Stem 4 — Heyde syndrome:

Stem 5 — Mallory-Weiss:

Stem 6 — Disposition:

Stem 7 — H. pylori follow-up:

Stem 8 — Anticoagulation reversal:

Stem 9 — Jehovah's Witness:

Stem 10 — Pediatric:

One-Line Recap

Upper GI bleeding management hinges on simultaneous resuscitation, empiric pharmacotherapy (PPI for all, octreotide + ceftriaxone for cirrhotics), risk stratification with Glasgow-Blatchford for disposition, and timely endoscopy within 24 hours for diagnosis and hemostasis — with secondary prevention driven by etiology (H. pylori eradication, NSAID avoidance, beta-blockers + EVL for varices, aspirin resumption within 7 days).

Board pearl: The single highest-yield intervention you can add in a cirrhotic UGIB stem is ceftriaxone — it carries the largest mortality benefit of any drug in this scenario and is the most commonly forgotten order on both written boards and CCS cases.

The CCS sequence to memorize: 2 large-bore IVs → IVF bolus → type & cross → labs (CBC, BMP, LFTs, PT/INR, lactate, troponin) → IV PPI → octreotide + ceftriaxone if cirrhotic → GI consult → EGD within 12–24h → restrictive transfusion (Hgb <7, or <8 if CAD) → ICU vs floor based on AIMS65/GBS.

The three "do not miss" diagnoses: aortoenteric fistula (prior AAA graft → CT angio first), variceal hemorrhage (cirrhosis → octreotide + ceftriaxone + EVL), and perforated ulcer (peritonitis → surgery, not endoscopy).

The discharge checklist: confirm hemostasis 24–72h post-EGD, transition to oral PPI BID × 2 weeks then daily × 6–8 weeks, test and treat H. pylori with quadruple therapy, confirm eradication ≥4 weeks post-treatment and ≥2 weeks off PPI, stop NSAIDs, resume aspirin within 1–7 days if indicated for CV protection, repeat EGD for gastric ulcers at 8–12 weeks to rule out malignancy, schedule PCP/GI follow-up before discharge.

The cirrhotic-specific bundle: non-selective beta-blocker (carvedilol preferred), serial EVL every 2–4 weeks until eradication, surveillance EGD every 6–12 months thereafter, lactulose for encephalopathy prophylaxis, vaccinate (HAV/HBV/pneumococcus/influenza), MELD-based transplant evaluation, abstinence counseling.