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:
- 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.