GI Bleed
ABCs
- assess airway, breathing, circulation, consciousness; record vitals
- if unstable → call for help immediately
- 2 large-bore IV lines (≥ 18G)
- urgent labs: CBC, RFT, coagulation profile
- cross-match and reserve 2 units PRBCs
- compare with previous Hb / labs
call for help early
- hemodynamic instability (hypotension, tachycardia), syncope, or altered mental status
- ongoing hematemesis or large-volume melena / hematochezia
- suspected variceal bleed (known cirrhosis) → earlier scope
- on antiplatelets / anticoagulants, or severe comorbidity (IHD, renal or liver disease)
HPI & examination
- bleeding details: onset, amount, color, frequency; prior episodes; recent endoscopy; baseline Hb
- upper GI (UGIB): hematemesis, melena; cirrhosis, PUD, varices, alcohol use
- lower GI (LGIB): fresh PR bleeding; hemorrhoids, diverticulosis, colorectal cancer, IBD
- medications: antiplatelets, anticoagulants, NSAIDs; last meal (type + timing)
- examination: abdominal, PR exam, signs of chronic liver disease
differentials
| category | condition | examples / causes |
|---|---|---|
| UGIB | peptic disease | PUD, gastritis (NSAIDs, H. pylori, alcohol, stress, steroids) |
| variceal bleeding | esophageal varices, gastric varices (often cirrhosis-related) | |
| mucosal tears | Mallory–Weiss tear | |
| vascular lesions | Dieulafoy lesion, AVM, angioectasia | |
| neoplasm | gastric or esophageal malignancy | |
| iatrogenic / other | post-endoscopy; swallowed blood (e.g. epistaxis) | |
| LGIB | diverticular disease | diverticulosis |
| anorectal | hemorrhoids | |
| vascular lesions | AVM, angioectasia | |
| inflammatory | colitis, IBD | |
| neoplasm | colorectal cancer, polyps | |
| ischemic | ischemic colitis |
treat
initial stabilization
- if hypotensive / dehydrated → NS bolus (≈ 1 L fast)
- NPO; cardiac monitor; IV fluids
- early GI consult for scope ± transfusion
monitoring & investigations
- repeat CBC by trend; coagulation and RFT as sent above
- high-risk (IHD / elderly) → Hs-Troponin, VBG, lactate, ECG
medications & transfusion
- Omeprazole (Losec) 80 mg IV STAT → infusion 8 mg/hr
- intermittent IV PPI (80 mg bolus then 40 mg 2–4 times daily) is an accepted alternative; evidence does not clearly favor either
- transfuse PRBCs: target Hb ≥ 7 g/dL (≥ 8 if cardiovascular disease)
- platelets and INR: no routine “correct to normal” target
- active LGIB: platelets around 50 × 10⁹/L before endoscopy is reasonable; higher does not reduce rebleeding and may increase mortality
- endoscopy generally safe up to INR ≤ 2.5
- reversal agents (including PCC) only for ongoing instability despite resuscitation, not routine correction
- hold antiplatelets / anticoagulants only after senior discussion + indication review; involve cardiology / hematology for high thrombotic-risk patients; reverse per coagulation page
- tranexamic acid: not routinely recommended in GI bleeding; HALT-IT trial showed no mortality benefit
- NG lavage: not routinely recommended; poor diagnostic yield, no outcome benefit; do not delay endoscopy
suspected variceal bleed / cirrhosis
- octreotide 50 mcg IV bolus → 50 mcg/h infusion (start before endoscopy)
- alternative: terlipressin 2 mg IV bolus then 1–2 mg IV q4–6h; monitor sodium (hyponatremia risk)
- ceftriaxone 1 g IV daily; prophylactic antibiotics reduce mortality
- refractory bleeding → balloon tamponade as bridge, discuss TIPS urgently; senior / GI / IR decision
endoscopy
- EGD within 24 hr; earlier if unstable or suspected variceal bleed
- Glasgow-Blatchford score supports triage and disposition; does not replace clinical judgment
- NPO 6–8 hr prior
- LGIB: ongoing hemodynamically significant hematochezia → CTA first (most useful within 4 hr), IR embolization if extravasation; stable → colonoscopy after resuscitation + bowel prep, urgency per GI / surgery; contact General Surgery early
disposition
- ICU / HDU: shock, ongoing bleeding, uncontrolled variceal bleed, or high-risk score; ward with telemetry + repeat Hb if stabilized; GI decides scope timing on all significant bleeds; senior review before discharge
- uncontrolled bleeding needing massive transfusion → massive hemorrhage
- shock persisting despite resuscitation → Advanced: Shock, Advanced: Vasopressors & Inotropes
calculator Glasgow-Blatchford · MDCalc ↗︎
evidence
| source | type |
|---|---|
| ACG 2021 upper GI/ulcer bleeding guideline | international guideline |
| ACG 2023 lower GI bleeding guideline | international guideline |
| Baveno VII portal hypertension consensus | international guideline |
| HALT-IT trial (TXA in GI bleeding) | randomized trial |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
go deeper MOC+ Vol 4 · Acute GI & Hepatology covers this in the full reference. or the complete set.
free the on-call checklist covers the whole shift on one printable page.
studying for the IM exam? IM Rapid Review covers GI bleed in the same format. see the sample chapter.
reviewed Jun 2026updated Sep 2026file complaint/gi-bleed