- Vital signs: postural vitals
- Any history of bleeding? Obvious site of bleeding?
- Estimate quantity of blood lost?
- Last Hgb, INR, PTT; good IV access?
- Meds: heparin, warfarin, clopidogrel, ASA
- It is important to stabilize the patient so that the appropriate
investigations can be performed ASAP by the appropriate team (surgery,
GI, IVR, etc.) if necessary.
- Melena: > 50–100 mL of blood has been lost.
- False alarm: Bismuth, iron supplement, red wine, etc.
- Hematochezia: can occur with UGIB after > 1 L of blood has
- Shock: clinical diagnosis: SBP < 90 mmHg + evidence of
inadequate tissue perfusion–urine output < 20 mL/h is a good indicator.
- Bleeding ulcer (peptic or duodenal); esophageal varices may present
with hematemesis or coffee ground emesis.
- It is not necessarily associated with nausea or pain.
- Melena is often present.
- NG tube aspiration of coffee-ground-like material is highly
suggestive of this diagnosis, although not always present (bleeding from
duodenal ulcer, etc.) Try to differentiate between variceal- and
ulcer-related bleed, as management differs.
- Suspected when the patient is having hematochezia.
- Melena, although suggestive of UGIB, can be present if the bleeding
is coming from the cecal region (or more distal).
- It is also useful to try to quantify the amount of blood in the
feces; blood being an irritant, a patient can possibly have numerous
small bowel movements.
Gross hematuria (in the absence of kidney disease)
- Traumatic urethral catheter and infection are common in-hospital
causes, especially for anticoagulated patients (but anticoagulation
alone is not responsible for hematuria)
- Assess bleeding site
- Upper GI source
- Hematemesis, coffee ground emesis
usually bleed above ligament of Trietz
- Lower GI source
(or large upper bleed)
red blood per rectum
- Ask about
w/known varices will bleed from a
nonvariceal source 20% of the time
bruising, prolonged bleed after minor
- Steroids, iron, bismuth, methotrexate
- Anticoagulant toxins, EtOH
- Liver dz
- Diabetes, COPD, peripheral vascular dz
- ABCs: assess for hemodynamic stability; make sure you have adequate,
large bore x 2 IV access.
- Signs of liver
erythema, gynecomastia, testicular atrophy
- Signs of
ecchymoses, petechiae, telangiectasia
- Abdominal exam
masses, ascites & hepatosplenomegaly
- Look for
surgical scars, listen for bruit
- Rectal exam
stool color, hemoccult
- Signs of
- Blood work: STAT: CBC, CMP,
Lactic Acid, INR, PTT; Type & cross + match
6 U PRBC.
- Hgb & Hct
may be normal during acute bleed
- May take
up to 6 hrs to equilibrate
- Increase PT
liver dz, fat malabsorption, abxs
- Increase PTT
- Congenital (factor VIII deficiency, von
Willebrand's dz) or acquired (DIC)
hypotension and shock
- Hypochloremic alkalosis
- Creatinine >
20:1 suggests upper GI source or severe
- Type & Cross x
6U PRBC if
bleed, signs of shock, elderly
type-specific blood if possible
- If not
- O- for
- ECG/monitoring, CK, trops, depending on the severity
- Try to localize the source of the bleeding from the history +
findings; consider NG tube.
- Hematuria: send urine for C+S, urinalysis.
- Give 2-4 Unit FFP if PT
increased and actively cause bleeding
- Transfuse platelets
GI Bleed Overview
Blood in Vomit
Blood in Stool
(+) Blood in NG
(-) Blood in NG
Upper GI Bleed
> 2 L/min
< 2 L/min
Tag Red cell study
Wait till bleeding stops & do Colonoscopy
(-) Blood in vomit
(+) Blood in vomit
Think Lower GI Bleed, Get stool guiac.
↑↑ BUN: Cr
- Nuclear labled RBC Scan - Can localize the site of bleed
- Angiogram - Requires Active Bleed.
-PUD most common
-Varices --> Octreotide, Propranolol
- Anoscopy or Sgmoidoscopy
Meckle's (> 2yo)
- PainLESS or Acute abdominal pain
- Dx: Tc 99 scan
- Tx: Surgery
Intussusepiton (< 2 yo)
- CRAMPY, Normal between episodes
- Post Rotavirus, Adenovirus
- Sausage- shaped mass
- Dx/Tx: Barrium
- Complication: Intussuseption.
- Ascending Colon (RIGHT Side)
- Sigmoid Colon (LEFT side)
- ESRD associated
- Aortic Stenosis
airway adequate, ventilation OK
Lethargic/altered mental status
Intractable vomiting of blood
Stages (and Symptoms)
I: (0-15% blood loss)
Normal or minimally elevated HR
II: (15-30% blood loss)
Tachycardia, tachypnea, cool skin,
delayed capillary refill
Decreased pulse pressure
III: (30-40% blood loss)
Tachycardia, tachypnea, hypotension
IV: (>40% blood loss)
Marked tachycardia, tachypnea, decr
SBP (DBP may be undetectable)
Lethargy/LOC, cool skin, pallor
- 2 large-bore
Peripheral lines preferred
- NS or LR
hypotensive, run wide open until stable
CVP in elderly w/CHF and decreased
- If still
unstable after 2L fluid
PRBC's or blood
Type-specific if possible
- O(+) if
- O(-) for
- Further measures
- Endoscopy if
- NG tube (if
endo not readily available)
Diagnostic use or to relieve emesis only
stained gastric aspirate will r/o
most profound GI bleeds
- Will not
treat upper GI bleed
done with large-bore tube (Ewald)
w/room temp H2O or NS
unstable/actively bleeding patients
- Upper GI
(endoscopy) consult AND
- Lower GI
- Fluid replacement if any sign of instability (bolus NS PRN).
- Transfer patient to a monitored setting.
- Consider Intubation for UGIB for airway protection
- Pantoprazole 80 mg IV bolus, followed by 8 mg/hr
- Octreotide 50 mcg bolus, followed by 25-50 mcg/hr infusion
x1-5 days (Alcoholics)
- Call for help—senior resident, fellow, attending, etc. The patient
may (will likely) need urgent intervention.
- HOLD heparin, warfarin, clopidogrel, ASA, etc.
- STOP BP
meds if hemodynamically unstable
- Reverse INR (if necessary). 2–4 units of FFP can be a good starting
point; the correction obtained with FFP is proportional to the INR (the
higher the INR, the more correction you’re likely to get).
- Three- or four-factor prothrombin complex concentrate (if available)
for life-threatening bleeding
- Vitamin K:
- 10 mg IV over 20 to 60 minutes, can be repeated
q12h; risk of anaphylaxis—to sustain the reversal obtained by the FFP.
- Make sure the patient is NPO (for intervention).
- Follow hemoglobin/hematocrit PRN (at least q6h)—Transfuse PRN:
- Don’t forget that those values are not necessarily representative of the
patient’s "true" values when there’s an acute bleed, so plan your
- Follow hemoglobin / hematocrit q6h x 24h then R/A.
- Consider reversing INR if necessary: low-dose vitamin K: 1 mg
PO x 1—the effects of this treatment will take a few hours.