Key Points
- Resuscitate first; use restrictive transfusion thresholds (e.g., Hb ~7 g/dL in stable, higher if coronary ischemia).
- CT angiography in brisk bleeding; colonoscopy within 24 h after prep in stabilized patients.
- Reverse/co-manage antithrombotics based on risk; avoid empiric octreotide/PPI unless upper source suspected.
Algorithm
- ABCs; large-bore IVs; labs including type & cross; resuscitate.
- Risk stratify; if ongoing hemodynamic instability → CT angiography ± IR embolization; otherwise prep and colonoscopy within 24 h.
- Reverse anticoagulation/antiplatelets selectively; identify and treat source (diverticular bleed, angioectasia, post-polypectomy).
Clinical Synopsis & Reasoning
For Gi Bleeding In The Ed Risk Scores Initial Therapy, frame the differential by acuity and pathophysiology, then align diagnostics to the leading hypotheses. Prioritize stabilization while obtaining high‑yield studies such as CBC/Coags/Type & Cross (Bleeding assessment/prep), CT Angiography (Localize active bleeding), Colonoscopy (prepped) (Diagnostic/therapeutic). Incorporate bedside imaging and targeted labs to define severity and identify complications; synthesize results with clinical trajectory to refine the working diagnosis and disposition needs.
Treatment Strategy & Disposition
Initiate disease‑directed therapy alongside supportive care, titrating to objective response. Pharmacologic options commonly include Reversal agents (PCC/Vit K/idarucizumab/andexanet), No routine octreotide/PPI. Use validated frameworks (e.g., Key Steps UGI Bleed) to guide escalation and site of care. Address precipitating factors, de‑escalate empiric therapies with data, and arrange follow‑up for monitoring and risk‑factor modification; admit patients with instability, high risk of deterioration, or needs for close monitoring.
Management Notes
Document stool color and hematemesis characteristics. Place NGT selectively; not required routinely.
Epidemiology / Risk Factors
- Older age, diverticulosis, angioectasias, antithrombotics
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CBC/Coags/Type & Cross | Bleeding assessment/prep | Low Hb; coagulopathy | Trend |
| CT Angiography | Localize active bleeding | Contrast extravasation | Best in brisk bleed |
| Colonoscopy (prepped) | Diagnostic/therapeutic | Source identified/treated | Within 24 h after stabilization |
Key Steps UGI Bleed
| Action | Notes |
|---|---|
| IV access + resuscitation | Restrictive transfusion thresholds |
| Risk scoring | GBS 0–1 consider discharge |
| PPI therapy | 80 mg bolus → 8 mg/h infusion |
| Variceal bundle | Octreotide + ceftriaxone |
| Disposition | ICU if unstable or high risk |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| PPI (IV) | H+/K+ ATPase inhibition | Hours | Non-variceal UGIB | Infection risk long-term; ED use |
| Packed RBC | O₂-carrying capacity | Immediate | Transfuse to Hgb threshold | Transfusion reactions; ED use |
| Octreotide (variceal) | Splanchnic vasoconstriction | Minutes | Acute variceal bleed | Abdominal cramps; ED use |
| Balanced crystalloids | Plasma volume expansion | Immediate | Resuscitation | Fluid overload; ED use |
| Ceftriaxone (cirrhosis) | Cephalosporin | Hours | SBP prophylaxis in variceal bleed | Allergy; ED use |
Prognosis / Complications
- Most stop spontaneously; rebleeding risk depends on etiology and comorbidity
Patient Education / Counseling
- Medication review; colon follow-up as indicated; return precautions
References
- ED GI Bleeding — Link