Upper Gastrointestinal Bleed
Gastroenterology
Illness script · Gastroenterology
Upper Gastrointestinal Bleed
Bleeding originating proximal to the ligament of Treitz, presenting with hematemesis, melena, or hematochezia with hemodynamic instability.
This illness script for Upper Gastrointestinal Bleed covers predisposing factors, classic presentation, mechanism, workup, management, and the clinical pivots that separate it from look-alikes—written for USMLE Step 1 and clerkship reasoning.
01
Predisposing factors
- Peptic ulcer disease (most common cause, ~50%); H. pylori and NSAIDs are top risk factors
- Cirrhosis/portal hypertension → esophageal or gastric varices (high mortality risk)
- Mallory-Weiss tear: forceful vomiting, alcoholism, retching
- Esophagitis/gastritis: alcohol, NSAIDs, steroids, stress
- Dieulafoy lesion: large submucosal artery, often in young men
- Aortoenteric fistula: prior aortic graft surgery (must not miss)
02
Presentation
- Hematemesis (bright red or coffee-ground emesis) — hallmark of UGIB
- Melena (black, tarry, malodorous stool) — as little as 50–100 mL of blood
- Hematochezia may occur with massive UGIB (>1000 mL); suggests brisk bleeding
- Signs of hemodynamic instability: tachycardia, hypotension, orthostasis
- Prior NSAID use, alcohol use, or known cirrhosis/varices on history
- Epigastric tenderness (PUD); spider angiomata, ascites, jaundice (cirrhosis/varices)
03
Pathophysiology
- Peptic ulcers: acid/H. pylori disrupts mucosal barrier → erosion into submucosal vessels
- Varices: portal HTN > 10–12 mmHg → portosystemic collaterals enlarge and rupture
- Mallory-Weiss: sudden rise in intraabdominal pressure tears gastroesophageal junction mucosa
- Massive UGIB → volume loss → hemodynamic compromise; blood in gut → melena/hematochezia
04
Diagnostics
- BMP, CBC, coags, type & crossmatch — first-line labs; BUN:Cr ratio >20:1 suggests UGIB
- Upper endoscopy (EGD) — gold standard: diagnosis + therapeutic
- Nasogastric lavage: bloody/coffee-ground return suggests active UGIB (not definitive)
- Glasgow-Blatchford score (pre-endoscopy) and Rockall score (post-endoscopy) risk-stratify patients
- Angiography or tagged RBC scan if endoscopy fails and bleeding is active
05
Management
- IV access (2 large-bore IVs), aggressive fluid resuscitation, transfuse pRBCs if Hgb <7 (or <8 in varices/ACS)
- IV PPI (pantoprazole bolus + infusion) for non-variceal bleeding; start empirically before EGD
- Variceal bleed: octreotide + IV ceftriaxone (SBP prophylaxis) + urgent EGD with band ligation
- EGD within 24 hours (within 12 hours for high-risk/variceal); epinephrine injection, thermal, clips for PUD
- TIPS or balloon tamponade (Sengstaken-Blakemore) as bridge for refractory variceal hemorrhage
- Avoid beta-blockers acutely in active variceal hemorrhage; hold NSAIDs/anticoagulants
06
Clinical pivots
How to separate this script from the look-alikes that show up on exams and on the wards.
Lower GI Bleed
LGIB causes hematochezia without hemodynamic instability and BUN:Cr ratio is normal (<20:1)
Mallory-Weiss Tear
Bleeding follows forceful vomiting/retching; typically self-limited without variceal features
Esophageal Varices
Painless massive hematemesis + stigmata of cirrhosis (ascites, jaundice, splenomegaly); no epigastric tenderness
Aortoenteric Fistula
Prior aortic graft surgery + herald bleed → catastrophic hemorrhage; must rule out urgently with CT/endoscopy
Keep reading
Full libraryEducational use only. This illness script is a study framework, not medical advice. Confirm decisions with current guidelines and your clinical supervisors.