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symptom.gi_bleed.ed.v1PRODUCTION
symptom.gi_bleed.ed.v1

GI bleed (ED workup — upper + lower undifferentiated)

symptomacuteundifferentiatedadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Bleed character (hematemesis / melena / hematochezia / occult), onset, volume, hemodynamic state, anchor source (UGI vs LGI vs occult) (Laine 2012; Strate 2016)

Inputs
4
Actions
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Advance rule
Set
Advance when

bleed characterized + hemodynamic risk classified

Patient inputs (34)

Age shifts priors: variceal/PUD peaks 50-70; diverticular/angiodysplasia >65; Meckel diverticulum pediatric (Laine 2012; Strate 2016)

Male preponderance for cirrhosis / variceal bleed; female preponderance for angiodysplasia / aortic stenosis-associated GI bleed (Heyde syndrome) (Strate 2016)

Hypotension flags massive bleed; orthostatics (SBP drop ≥20 mmHg) indicate >15% volume loss (Laine 2012)

Tachycardia early; HR >120 implies >30% volume loss; shock index (HR/SBP) >1 → severe (Laine 2012)

Tachypnea in compensated hemorrhagic shock or aspiration (Laine 2012)

Hypoxia → aspiration of blood / pulmonary edema from over-resuscitation

Fever in cirrhotic + GI bleed → SBP empiric ceftriaxone per AASLD (Garcia-Tsao 2017)

Cirrhosis triples mortality in UGI bleed; mandates variceal pathway + ceftriaxone prophylaxis + octreotide (Garcia-Tsao 2017 PMID 21670378)

Prior PUD / varices / Mallory-Weiss / Dieulafoy raise pretest for recurrence (Laine 2012)

NSAID-induced PUD is leading non-H. pylori cause of UGI bleed; deprescribe + PPI prophylaxis (Laine 2012; FDA PPI long-term PMID 27069334)

Warfarin / DOAC / DAPT raise bleed severity + complicate hemostasis; reversal pathway (4F-PCC for warfarin; andexanet/idarucizumab for DOAC; transfusion for antiplatelet)

Aorto-enteric fistula classically presents with herald bleed → massive bleed; STAT CTA aorta + vascular surgery (Laine 2012)

Underlying CAD + acute anemia → demand ischemia (type 2 MI) — keep Hgb >7-8 g/dL; route to cardio.nstemi.core.v1 if hs-cTn rise

PUD / mesenteric ischemia / pancreatitis / aorto-enteric fistula / perforation — pain pattern differentiates (route to symptom.abdominal_pain.ed.v1 overlay)

Retching before hematemesis = Mallory-Weiss; persistent vomiting + chest pain + subcutaneous emphysema = Boerhaave

Syncope/presyncope with GI bleed implies significant volume loss → high pretest for massive bleed (Laine 2012)

Hematemesis / coffee-ground / melena / hematochezia / occult — each anchors location and acuity (Laine 2012)

Acute vs subacute vs chronic — drives resuscitation tempo and intervention urgency (Laine 2012)

Estimated volume (tablespoons / cups / "filled the toilet") + frequency → resuscitation magnitude (Laine 2012)

Hgb / Hct may be initially normal in acute bleed (equilibrium ~24 h); platelet count <50 alters transfusion threshold; serial Hgb drives transfusion decisions

BUN:Cr >30 (with normal renal function) is signature of UGI bleed from absorbed Hgb protein load (Laine 2012); AKI in poor perfusion

AST/ALT/bili/alb/INR for cirrhosis recognition + Child-Pugh / MELD severity (Garcia-Tsao 2017)

INR / PTT for coagulopathy; cirrhotic patients have rebalanced hemostasis (not always corrected with FFP); on anticoagulant patients need reversal pathway

MANDATORY type & cross ≥2-4 units pRBC; ≥4-6 units if hemodynamically unstable; activate massive transfusion protocol if needed

Lactate >2 raises shock / mesenteric ischemia / sepsis prior; lactate clearance tracks resuscitation adequacy (SSC 2026)

ECG for demand ischemia screen + baseline rhythm; ST-changes prompt cardio.nstemi.core.v1 overlay

CTA abdomen if aorto-enteric fistula suspected (prior AAA repair / aortic graft + UGI bleed) — STAT vascular surgery (Laine 2012)

CT angiography for active LGIB localization (>0.3 mL/min bleed rate) → IR embolization (Strate 2016 PMID 24042191)

Tc-99m RBC scintigraphy for slow / intermittent obscure GI bleed when EGD + colonoscopy negative (Strate 2016)

Pelvic radiation → radiation proctitis (chronic hematochezia) (Strate 2016)

Jaundice + ascites → cirrhosis → variceal source until proven otherwise (Garcia-Tsao 2017 PMID 21670378)

New-onset change + LGI bleed + weight loss + age >50 → colorectal CA screen (Strate 2016)

Hs-cTn for demand ischemia (type 2 MI) — common in massive bleed + underlying CAD; route to cardio.nstemi.core.v1 if rise/fall pattern

Free air under diaphragm = perforated viscus (PUD perforation); mediastinal widening / pneumomediastinum = Boerhaave

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (14)

14 need judgement
  • informationallife_threateningmassive_bleed_hemodynamic_instability
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningvariceal_bleed_cirrhosis
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningaorto_enteric_fistula
    Recent AAA repair OR aortic graft + UGI bleed (often herald bleed → massive) — STAT CTA aorta + vascular surgery; high mortality (Laine 2012)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereupper_gi_bleed_hematemesis
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelower_gi_bleed_hematochezia
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverensaid_anticoag_induced_bleed
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredieulafoy_lesion
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremallory_weiss_boerhaave
    Repeated retching/vomiting before hematemesis → Mallory-Weiss tear (usually self-limited) vs Boerhaave (transmural — chest pain + subcutaneous emphysema + mediastinal widening; surgical emergency)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredemand_ischemia_type2_mi
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresepsis_post_endoscopy
    Post-EGD/ERCP cholangitis OR aspiration pneumonia after large-volume bleed — qSOFA ≥2 / lactate >2 / SBP <100 → sepsis bundle (SSC 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehepatic_encephalopathy_overlay
    Cirrhotic post-GI bleed + AMS / asterixis → hepatic encephalopathy from blood-protein load; lactulose + rifaximin; ammonia level
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecolonic_diverticular_bleed
    Painless large-volume hematochezia in patient >60 with diverticulosis — most common cause of LGIB; usually self-limits (75-80%); recurrence in ~25% (Strate 2016 PMID 24042191)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateangiodysplasia_avm
    Recurrent painless GI bleed in elderly + aortic stenosis (Heyde syndrome) + ESRD — angiodysplasia / arteriovenous malformation; capsule endoscopy + endoscopic argon plasma coagulation (Strate 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildoccult_iron_deficiency_anemia
    Positive FOBT / iron-deficiency anemia without overt bleeding — obscure / occult bleed; bidirectional endoscopy (EGD + colonoscopy) → capsule endoscopy if negative (Strate 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

ed playbook — drug actions (11)

  1. 1. isotonic crystalloid (LR preferred)
    500 mL-1 L bolus, repeat to MAP ≥65 or until pRBC available • IV • titrate to MAP ≥65
    trigger: Hypotension (SBP <90) OR shock index >1
    Bridge to pRBC; LR preferred over NS in cirrhotic to avoid hyperchloremic acidosis (SSC 2026); avoid over-resuscitation in variceal bleed (raises portal pressure)
  2. 2. pRBC transfusion
    1-2 units pRBC; restrictive Hgb trigger 7 g/dL stable, 8 g/dL if cardiac comorbidity • IV • serial Hgb q4-6h driving repeat dosing
    trigger: Hgb <7 (or <8 if cardiac) OR active bleed with hemodynamic instability
    Villanueva NEJM 2013 — restrictive transfusion strategy reduced mortality in UGI bleed; ACG 2023 PMID 36038243 endorses Hgb 7 g/dL trigger
  3. 3. pantoprazole IV (or omeprazole)
    rxcui 40790
    80 mg IV bolus then 8 mg/hr infusion x 72 h (or 80 mg IV q12h) • IV • continuous infusion or q12h
    trigger: ALL suspected UGI bleed pending EGD
    Laine 2012 PMID 22825597; ACG 2023 PMID 36038243 — pre-endoscopy IV PPI reduces high-risk stigmata at endoscopy + need for endoscopic Rx; transition to PO PPI 40 mg BID x 2 wks then daily after hemostasis
  4. 4. octreotide
    50 mcg IV bolus then 50 mcg/hr infusion x 2-5 days • IV • continuous infusion
    trigger: Cirrhosis OR known portal HTN OR suspected variceal source
    Garcia-Tsao 2017 PMID 21670378 — splanchnic vasoconstriction reduces variceal blood flow; combined with endoscopic banding reduces rebleed + mortality; route to gi.variceal_bleed.v1
  5. 5. ceftriaxone
    1 g IV daily x 5-7 days • IV • daily
    trigger: Cirrhotic UGI bleed (variceal or non-variceal)
    Garcia-Tsao 2017 — antibiotic prophylaxis reduces SBP, rebleed, mortality in cirrhotic GI bleed; ceftriaxone preferred over fluoroquinolones (resistance)
  6. 6. erythromycin
    250 mg IV 30-90 min pre-EGD • IV • once pre-procedure
    trigger: Large-volume hematemesis or coffee-ground emesis pre-EGD
    Promotility agent clears gastric blood for endoscopic visualization; reduces need for repeat EGD; Laine 2012 PMID 22825597
  7. 7. 4-factor PCC (KCentra)
    rxcui 1670383
    INR 2-3.9: 25 units/kg; INR 4-6: 35 units/kg; INR >6: 50 units/kg (max 5000 units) • IV • once + vitamin K 10 mg IV
    trigger: Warfarin reversal with INR >1.5 + active GI bleed
    AHA/ASA + AC Forum — 4F-PCC + vitamin K for emergent warfarin reversal; faster than FFP and lower volume load
  8. 8. andexanet alfa OR idarucizumab
    Andexanet (apixaban/rivaroxaban reversal): low-dose 400 mg bolus + 4 mg/min x 2 h or high-dose 800 mg bolus + 8 mg/min; idarucizumab (dabigatran reversal): 5 g IV (two 2.5 g vials) • IV • once
    trigger: Active GI bleed on DOAC within 18 h of last dose
    ANNEXA-4 (andexanet) + RE-VERSE AD (idarucizumab) — targeted DOAC reversal; alternative 4F-PCC 50 units/kg if andexanet unavailable
  9. 9. platelets
    1 apheresis unit (or 6-pack random donor); target plt >50, >100 if intracranial bleed concern • IV • as needed
    trigger: Plt <50 with active bleed OR on antiplatelet agent
    ACG 2023 PMID 36038243 — platelet transfusion for thrombocytopenia or antiplatelet-associated bleed
  10. 10. FFP
    10-15 mL/kg • IV • as needed
    trigger: INR >1.5 in non-warfarin / non-cirrhotic context with active bleed
    Reserve for non-cirrhotic coagulopathy; in cirrhosis INR does not reflect bleeding risk (rebalanced hemostasis) and FFP raises portal pressure
  11. 11. esmolol or labetalol
    Esmolol 500 mcg/kg bolus then 50 mcg/kg/min; labetalol 10-20 mg IV • IV • titrate HR <60 + SBP <120
    trigger: Suspected aorto-enteric fistula (prior AAA repair + UGI bleed) — impulse control until OR
    AHA 2022 Acute Aortic Disease — beta-blocker before vasodilator; STAT CTA + vascular surgery → vasc.aaa.v1

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: 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); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**GI bleed (ED workup — upper + lower undifferentiated)** (symptom.gi_bleed.ed.v1).
Phenotype framing: UGI phenotypes (Laine 2012): PUD ~30-50%, varices ~10-15%, Mallory-Weiss ~5-10%, esophagitis ~5%, gastritis ~5%, malignancy ~5%, Dieulafoy ~1-3%, aorto-enteric fistula <1% but lethal. LGI phenotypes (Strate 2016): diverticular ~30-40%, angiodysplasia ~5-15%, colitis (ischemic/infectious/IBD) ~10-20%, neoplasm ~10%, hemorrhoidal/anorectal ~10%, post-polypectomy ~5%, radiation proctitis ~3%. Occult: angiodysplasia / NSAID-PUD / malignancy.
Scope: Bleed character (hematemesis / melena / hematochezia / occult), onset, volume, hemodynamic state, anchor source (UGI vs LGI vs occult) (Laine 2012; Strate 2016)

No severity triggers fired against current inputs.

Plan

No regimen axis selected (engine has no regimen_axes or could not match).

Setting playbook (ed) — Source-anchored triage (UGI vs LGI vs occult); rule out life-threats (massive bleed / aorto-enteric fistula / variceal bleed / Boerhaave / perforated PUD / demand ischemia); risk-stratify (Glasgow-Blatchford / Rockall / AIMS65 / Oakland); resuscitate (restrictive Hgb 7 g/dL trigger per Villanueva NEJM 2013); reverse anticoagulation; activate endoscopy / IR / surgery pathway; route to dedicated engine (Laine 2012 PMID 22825597; Strate 2016 PMID 24042191; ACG 2023 PMID 36038243)
1. isotonic crystalloid (LR preferred) 500 mL-1 L bolus, repeat to MAP ≥65 or until pRBC available IV titrate to MAP ≥65 — Hypotension (SBP <90) OR shock index >1 (Bridge to pRBC; LR preferred over NS in cirrhotic to avoid hyperchloremic acidosis (SSC 2026); avoid over-resuscitation in variceal bleed (raises portal pressure))
2. pRBC transfusion 1-2 units pRBC; restrictive Hgb trigger 7 g/dL stable, 8 g/dL if cardiac comorbidity IV serial Hgb q4-6h driving repeat dosing — Hgb <7 (or <8 if cardiac) OR active bleed with hemodynamic instability (Villanueva NEJM 2013 — restrictive transfusion strategy reduced mortality in UGI bleed; ACG 2023 PMID 36038243 endorses Hgb 7 g/dL trigger)
3. pantoprazole IV (or omeprazole) 80 mg IV bolus then 8 mg/hr infusion x 72 h (or 80 mg IV q12h) IV continuous infusion or q12h — ALL suspected UGI bleed pending EGD (Laine 2012 PMID 22825597; ACG 2023 PMID 36038243 — pre-endoscopy IV PPI reduces high-risk stigmata at endoscopy + need for endoscopic Rx; transition to PO PPI 40 mg BID x 2 wks then daily after hemostasis)
4. octreotide 50 mcg IV bolus then 50 mcg/hr infusion x 2-5 days IV continuous infusion — Cirrhosis OR known portal HTN OR suspected variceal source (Garcia-Tsao 2017 PMID 21670378 — splanchnic vasoconstriction reduces variceal blood flow; combined with endoscopic banding reduces rebleed + mortality; route to gi.variceal_bleed.v1)
5. ceftriaxone 1 g IV daily x 5-7 days IV daily — Cirrhotic UGI bleed (variceal or non-variceal) (Garcia-Tsao 2017 — antibiotic prophylaxis reduces SBP, rebleed, mortality in cirrhotic GI bleed; ceftriaxone preferred over fluoroquinolones (resistance))
6. erythromycin 250 mg IV 30-90 min pre-EGD IV once pre-procedure — Large-volume hematemesis or coffee-ground emesis pre-EGD (Promotility agent clears gastric blood for endoscopic visualization; reduces need for repeat EGD; Laine 2012 PMID 22825597)
7. 4-factor PCC (KCentra) INR 2-3.9: 25 units/kg; INR 4-6: 35 units/kg; INR >6: 50 units/kg (max 5000 units) IV once + vitamin K 10 mg IV — Warfarin reversal with INR >1.5 + active GI bleed (AHA/ASA + AC Forum — 4F-PCC + vitamin K for emergent warfarin reversal; faster than FFP and lower volume load)
8. andexanet alfa OR idarucizumab Andexanet (apixaban/rivaroxaban reversal): low-dose 400 mg bolus + 4 mg/min x 2 h or high-dose 800 mg bolus + 8 mg/min; idarucizumab (dabigatran reversal): 5 g IV (two 2.5 g vials) IV once — Active GI bleed on DOAC within 18 h of last dose (ANNEXA-4 (andexanet) + RE-VERSE AD (idarucizumab) — targeted DOAC reversal; alternative 4F-PCC 50 units/kg if andexanet unavailable)
9. platelets 1 apheresis unit (or 6-pack random donor); target plt >50, >100 if intracranial bleed concern IV as needed — Plt <50 with active bleed OR on antiplatelet agent (ACG 2023 PMID 36038243 — platelet transfusion for thrombocytopenia or antiplatelet-associated bleed)
10. FFP 10-15 mL/kg IV as needed — INR >1.5 in non-warfarin / non-cirrhotic context with active bleed (Reserve for non-cirrhotic coagulopathy; in cirrhosis INR does not reflect bleeding risk (rebalanced hemostasis) and FFP raises portal pressure)
11. esmolol or labetalol Esmolol 500 mcg/kg bolus then 50 mcg/kg/min; labetalol 10-20 mg IV IV titrate HR <60 + SBP <120 — Suspected aorto-enteric fistula (prior AAA repair + UGI bleed) — impulse control until OR (AHA 2022 Acute Aortic Disease — beta-blocker before vasodilator; STAT CTA + vascular surgery → vasc.aaa.v1)

Non-pharmacologic actions:
- Two large-bore IVs (16-18 gauge); central line if peripheral access fails or vasopressors needed
- Type & cross ≥2-4 units pRBC; activate massive transfusion protocol if SBP <90 despite 2 L crystalloid
- NPO until disposition (potential EGD / colonoscopy / OR)
- NG tube placement — controversial; useful for blood clearance pre-EGD but not for diagnosis (sensitivity poor)
- GI consult for emergent EGD within 24 h (≤12 h if hemodynamic instability or variceal)
- IR consult for active LGIB with positive CTA or refractory UGI bleed → embolization
- Vascular surgery + STAT CTA aorta if aorto-enteric fistula suspected
- Thoracic surgery for Boerhaave (esophageal perforation)
- Hepatology consult for cirrhotic variceal bleed → TIPS if refractory
- Foley catheter for urine output monitoring; A-line if vasopressors

Monitoring

Setting (ed) monitoring:
- Vital signs q15 min × 1 h then q30 min × 4 h then per disposition
- Continuous SpO2 + telemetry (especially with cardiac comorbidity)
- Serial Hgb q4-6h × 24 h then q12-24h
- Lactate trend q2-4h until normalized
- Urine output goal ≥0.5 mL/kg/h
- Serial abdominal exams (perforation watch — rigidity, rebound, free air on repeat imaging)
- Mental status (encephalopathy in cirrhotic post-bleed)
- Repeat type & cross / activate MTP if ongoing transfusion need

Follow-up plan: 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
- Close-out criterion: discharge bundle prescribed + follow-up scheduled

Monitoring phase: Serial vitals q15 min × 1 h then q30 min × 4 h; serial Hgb q4-6h × 24 h then q12-24h; lactate clearance; urine output ≥0.5 mL/kg/h; mental status; serial abdominal exams (perforation watch); telemetry if cardiac comorbidity

Disposition

Current setting: ed — Source-anchored triage (UGI vs LGI vs occult); rule out life-threats (massive bleed / aorto-enteric fistula / variceal bleed / Boerhaave / perforated PUD / demand ischemia); risk-stratify (Glasgow-Blatchford / Rockall / AIMS65 / Oakland); resuscitate (restrictive Hgb 7 g/dL trigger per Villanueva NEJM 2013); reverse anticoagulation; activate endoscopy / IR / surgery pathway; route to dedicated engine (Laine 2012 PMID 22825597; Strate 2016 PMID 24042191; ACG 2023 PMID 36038243)

Disposition criteria:
- Discharge: GBS 0-1 + stable vitals + reliable PCP follow-up ≤48-72 h + outpatient EGD ≤2 wks (Laine 2012)
- Observation: GBS 2-6 with stable vitals + serial Hgb stable × 6 h; suitable for short-stay unit
- Admit: GBS ≥7 OR Rockall ≥3 OR AIMS65 ≥2 OR ongoing transfusion need; obscure bleed with negative initial workup
- ICU: hemodynamic instability; massive transfusion; cirrhotic variceal bleed; suspected aorto-enteric fistula; demand ischemia; perforation; AMS from hepatic encephalopathy
- OR direct: aorto-enteric fistula; Boerhaave; perforated PUD; refractory bleed despite endoscopic + IR (surgical hemostasis); strangulated abdominal source

Escalation triggers (move to higher acuity):
- Persistent SBP <90 despite 2 L crystalloid + 2 units pRBC → activate massive transfusion protocol (1:1:1 pRBC:FFP:platelets); call ICU + GI + IR + surgery
- Suspected aorto-enteric fistula (prior AAA repair + UGI bleed) → STAT CTA aorta + vascular surgery → vasc.aaa.v1 (consult-based; not in registry as a separate engine)
- Cirrhotic UGI bleed with variceal source → octreotide + ceftriaxone + emergent EGD banding → gi.variceal_bleed.v1
- Cirrhotic decompensation overlay → gi.cirrhosis.core.v1
- Active LGIB with hemodynamic instability + positive CTA → IR embolization (vs colonoscopy after prep if stable) → gi.lgib.core.v1
- PUD with high-risk Forrest stigmata (Ia/Ib/IIa) → endoscopic Rx (epi injection + thermal/clip) + IV PPI 72 h infusion → gi.peptic-ulcer.core.v1 or gi.ugib.core.v1
- Demand ischemia (hs-cTn rise + ECG ST-changes) → maintain Hgb >8, route to cardio.nstemi.core.v1
- Sepsis (qSOFA ≥2 OR lactate >2 — aspiration / cholangitis post-ERCP) → SSC bundle → id.sepsis.core.v1
- Boerhaave (esophageal perforation post-emesis with chest pain + pneumomediastinum) → STAT thoracic surgery
- Hepatic encephalopathy from blood-protein load → lactulose + rifaximin → gi.hepatic-encephalopathy.core.v1

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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] 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] Recent AAA repair OR aortic graft + UGI bleed (often herald bleed → massive) — STAT CTA aorta + vascular surgery; high mortality (Laine 2012)

Citations

- 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 [PMID:30910853](https://pubmed.ncbi.nlm.nih.gov/30910853/)
- Cited evidence (PMID 36949934) [PMID:36949934](https://pubmed.ncbi.nlm.nih.gov/36949934/)

Last reconciled with current guidelines: 2026-05-30.
References
  • 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 — PMID:30910853
  • Cited evidence (PMID 36949934) — PMID:36949934