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Approach to gi bleeding

The same eight steps, every presentation: threats first, then the history and exam that discriminate, one honest sentence, a mechanism-grouped differential, and the tests read in order.

  1. Immediate threats

    • Hemodynamic instability: two large-bore IVs before any diagnostics
    • Variceal bleeding in known or suspected cirrhosis
    • The anticoagulated bleed
    • Ongoing hematemesis with airway risk

  2. History that discriminates

    • Up or down: hematemesis and melena (upper) versus fresh red rectal blood (lower, usually)
    • NSAIDs, anticoagulants, antiplatelet agents, alcohol
    • Liver disease stigmata history; prior bleeds and endoscopies
    • Weight loss and change in habit for the malignancy weight

  3. Examination

    • The hemodynamic exam first, including orthostatics when safe
    • Stigmata of chronic liver disease
    • The rectal exam that makes melena a fact instead of a report

  4. Problem representation

    Melena with an 18-point hemoglobin fall in a cirrhotic (variceal weight, protocol care) versus painless fresh bleeding in a well 70-year-old (diverticular weight).

  5. Differential, by mechanism

    Upper

    • Peptic ulcer
    • Varices
    • Esophagitis and Mallory-Weiss
    • Malignancy
    • Dieulafoy and rarities

    Lower

    • Diverticular bleeding
    • Angiodysplasia
    • Colitis (ischemic, infectious, inflammatory)
    • Malignancy and polyps
    • Hemorrhoids (after excluding above)

  6. Investigations

    • CBC trended, coagulation, group and screen, urea-to-creatinine ratio
    • Risk scores at the door (Glasgow-Blatchford for upper bleeds)
    • Endoscopy timed to risk; CT angiography for brisk obscure bleeding

  7. Interpretation

    • A normal first hemoglobin in a brisk bleed is dilutionally late, not reassuring
    • Urea rising out of proportion to creatinine supports an upper source
    • Restrictive transfusion (around 70 g/L) outperforms liberal targets, most emphatically in varices

  8. Next steps

    • Cirrhotic bleeds get vasoactives and antibiotics before the scope
    • Anticoagulation reversal is a named decision with the indication weighed out loud
    • Every bleed leaves with a documented rebleed plan

Connected

CaseThe consult caseFluidThe ascites that travels with it

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