Patient handout

GI bleed (ED workup — upper + lower undifferentiated)

PRODUCTION

1. Your condition

This handout is for gi bleed (ed workup — upper + lower undifferentiated). Your care team identified this based on: hematemesis (bright red or coffee-ground emesis) — upper gi bleed proximal to ligament of treitz (laine am j gastro 2012 pmid 22825597; acg 2023 pmid 36038243).

Other reasons your team may use this plan: melena (black tarry stool) — usually upper gi source (~90%); lower source if right-sided + slow transit (laine 2012); hematochezia (bright red blood per rectum) — lower gi source ~85%; massive ugi bleed ~15% (strate acg 2016 pmid 24042191); occult bleed — positive fobt / iron-deficiency anemia without overt bleeding (strate 2016).

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

SBP <90 OR HR >120 OR shock index >1 OR Hgb drop ≥2 g/dL within 24 h with GI bleed — life-threat; activate massive transfusion protocol (Laine 2012 PMID 22825597)(life-threatening)
Hematemesis (bright red OR coffee-ground) OR melena with hemodynamic features — UGI source proximal to ligament of Treitz; pre-endoscopy IV PPI + risk-stratify with Glasgow-Blatchford; EGD within 24 h (Laine 2012; ACG 2023 PMID 36038243)
Known cirrhosis OR portal HTN OR prior varices/EGD banding + UGI bleed — variceal phenotype; octreotide + ceftriaxone + emergent EGD banding (Garcia-Tsao AASLD 2017 PMID 21670378)(life-threatening)
Hematochezia (bright red blood per rectum) — LGI source ~85% (diverticular / angiodysplasia / colitis / hemorrhoidal / post-polypectomy / radiation proctitis); HOWEVER ~15% are massive UGI bleed with brisk transit (Strate ACG 2016 PMID 24042191)
GI bleed in patient on NSAID / aspirin / DOAC / warfarin / DAPT — deprescribe offending agent (if possible), reverse anticoagulation, PPI prophylaxis going forward (Laine 2012; FDA PPI long-term PMID 27069334)
Recent AAA repair OR aortic graft + UGI bleed (often herald bleed → massive) — STAT CTA aorta + vascular surgery; high mortality (Laine 2012)(life-threatening)
Recurrent massive UGI bleed with normal-appearing mucosa at index EGD — submucosal arteriole (Dieulafoy lesion); requires repeat EGD with hemostatic therapy (clip / band ligation / thermal) (Laine 2012)
Repeated retching/vomiting before hematemesis → Mallory-Weiss tear (usually self-limited) vs Boerhaave (transmural — chest pain + subcutaneous emphysema + mediastinal widening; surgical emergency)
Massive GI bleed + cardiac comorbidity → demand ischemia (type 2 MI); hs-cTn rise/fall pattern + ECG ST-T changes; maintain Hgb >8 g/dL; route to cardio.nstemi.core.v1
Post-EGD/ERCP cholangitis OR aspiration pneumonia after large-volume bleed — qSOFA ≥2 / lactate >2 / SBP <100 → sepsis bundle (SSC 2026)
Cirrhotic post-GI bleed + AMS / asterixis → hepatic encephalopathy from blood-protein load; lactulose + rifaximin; ammonia level

5. Follow-up

Discharged low-risk UGI bleed: PPI 8 wks + H. pylori test-and-treat + outpatient EGD ≤2 wks + return precautions; cirrhotic post-bleed: 2° prophylaxis (NSBB + endoscopic surveillance per AASLD); discharge bundle (NSAID deprescribe, alcohol cessation counseling); LGIB diverticular: low-residue diet + outpatient colonoscopy 4-8 wks; H. pylori-positive PUD → triple/quadruple therapy

6. Sources

Guideline: 2012 Laine Am J Gastro UGI bleed + 2023 ACG UGI bleed (Laine) + 2017 ESGE UGI bleed + 2016 Strate ACG LGIB + 2017 Garcia-Tsao AASLD variceal bleed + 2000 Blatchford Lancet GBS + 2013 Villanueva NEJM restrictive transfusion + 2026 SSC sepsis + FDA PPI long-term