Evaluation and Management of Gastrointestinal Bleeding

Key Historical Features

Quantity

Patient’s estimate

Symptoms suggestive of anemia/volume depletion: (pre)syncope, dyspnea

Appearance/Location

Distinguish upper from lower GI bleding

PMH

Prior episodes and source

History of aortic aneurysm graft

Comorbidities: presence of CAD, CHF, liver disease or diabetes increases mortality

Medications/substance use

Gastrotoxic, anti-coagulants, anti-platelet agents

Alcohol abuse

Key Physical Findings

Vital signs

Tachycardia or hypotension

Eyes

Conjuntival pallor suggests anemia

Scleral icterus suggests liver disease

Abdomen

Hyperactive bowel sounds may be present in UGIB (blood is cathartic)

Epigastric tenderness to palpation suggests PUD

Diffuse tenderness suggests bowel ischemia, obstruction/ileus, or perforation

Rectal (digital, anoscopy)

May reveal fissures, hemorrhoids or polyps

Labs/Diagnostic Tests

• CBC: consider transfusion for Hb <8-10g/dL particularly in elderly or those with CAD
• BMP: BUN:creatinine > 36 in the absence of renal failure suggests UGIB
• PT/PTT/INR: coagulopathy
• Lactate: elevated in bowel ischemia or systemic hypoperfusion
• T&S or T&C
• ECG: screen for myocardial ischemia

Blatchford Scoring System

Item	Value	Points
BUN	18-22	2
	22-28	3
	28-70	4
	>70	6
Hb (male)	12-13	1
	10-12	3
	<10	6
Hb (female)	10-12	1
	<10	6
SBP	100-109	1
	90-99	2
	<90	3
Other	HR > 100	1
	Melena	1
	Syncope	2
	Liver disease	2
	Heart failure	2

References:

1. Goralnick, E., & Meguerdichian, D. (2013). Gastrointestinal Bleeding. In Rosen's Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 248-253). Elsevier Health Sciences.