Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Resuscitate; establish large-bore access; labs and type & cross; start IV PPI.
- Risk-stratify and consult GI; perform early endoscopy (<24 h; sooner if unstable).
- Apply endoscopic therapy for high-risk lesions; plan post-endoscopic PPI and antithrombotic strategy; arrange follow-up.
Clinical Synopsis & Reasoning
Hematemesis or melena with hemodynamic changes suggests upper GI bleeding. Resuscitate with balanced transfusion strategy, start high-dose IV PPI, risk-stratify (GBS/Rockall), and arrange early endoscopy with endoscopic hemostasis for high-risk stigmata; resume antithrombotics per risk.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| CBC, coagulation profile, type & cross | Resuscitation | Anemia/coagulopathy | Guide transfusion/reversal |
| BUN/Cr and NG aspirate (selected) | Adjunct | Upper source more likely with elevated BUN | — |
| Risk scores (GBS, Rockall) | Disposition | Predict need for intervention | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Hemodynamic instability or ongoing hematemesis | High mortality | Resuscitate; ICU; urgent endoscopy |
| Anticoagulant/antiplatelet use | Bleeding risk | Reversal/hold agents; cardiology input if needed |
| High risk scores (GBS ≥12, Rockall high) | Adverse outcomes | Early endoscopy (<24 h) |
| Suspected ulcer with visible vessel/active bleed | Rebleed risk | Endoscopic therapy + high-dose PPI |
| Failure of endoscopic therapy | Persistent hemorrhage | IR embolization or surgery |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Pantoprazole 80 mg IV bolus → 8 mg/h infusion (or 40 mg IV BID) | PPI | Hours | Stabilize clot and reduce rebleed | Post-endoscopy step-down dosing |
| Transfusion strategy (Hb <7–8 g/dL) | Blood products | Hours | Restrictive threshold | Individualize for CAD |
| Reversal agents (vitamin K, PCC) and hold antithrombotics | Hemostasis | Hours | If coagulopathy present | Restart per risk/benefit |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- ACG guideline on non-variceal upper GI bleeding — Link