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  Aggressive resuscitative measures (intravenous access, crystalloid bolus, and blood products) are necessary in unstable patients with gastrointestinal (GI) bleeding.

  
  
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  A negative nasogastric lavage does not completely exclude an upper GI bleed.

  
  
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  A brisk upper GI bleed should be considered in the differential of patients who present with hematochezia.

  
  
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  Octreotide should be administered in patients with liver disease and significant upper GI bleeding, even when the diagnosis of esophageal varices has not been confirmed.

  
  
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  Emergent endoscopy should be arranged when active upper GI bleeding is present.

Gastrointestinal (GI) bleeding accounts for 5% of admissions from the emergency department (ED). An intervention is required to stop ongoing hemorrhage in 10% of patients. Bleeding can occur anywhere along the GI tract and can be grossly divided into upper and lower sources. Upper GI bleeding is defined as occurring proximal to the ligament of Treitz (the suspensory ligament of the duodenum). Lower GI bleeding is defined as occurring distal to the ligament of Treitz. Upper GI bleeding is 4–8 times more common than lower GI bleeding.

It is not always possible to clinically distinguish between upper and lower GI bleeding in the ED, but appearance of the gastric contents and stool can provide clues to the source of the hemorrhage. Hematemesis is the vomiting of blood and indicates an upper GI bleed. “Coffee ground” emesis suggests that the blood has partially digested and that bleeding is either slow or has stopped. A nasogastric (NG) tube aspirate positive for blood also indicates an upper GI source of bleeding. NG lavage can be negative in 25% of patients with an upper GI source of bleeding because the nasogastric tube does not reliably pass the pylorus.

Melena is black, tarry stool that reflects the presence of blood in the GI tract for more than 8 hours. At least 300 mL of blood must be present to produce melena. Melena is 4 times more likely to be from an upper GI source of bleeding and almost always reflects bleeding proximal to the right side of the colon. Hematochezia is bright red or maroon-colored blood per rectum. It is 6 times more likely to be from a lower GI source. An exception is a rapid upper GI source of bleeding. Hematochezia is present in 10% of upper GI bleeds.

The three most common causes of upper GI bleeding are peptic ulcer disease, gastritis, and varices (Table 30-1). Lower GI bleeding may be due to multiple causes, but diverticulosis is most common (Table 30-2). Less common causes include pseudomembranous colitis, infectious diarrhea, aortoenteric fistula, radiation colitis, mesenteric ischemia, and Meckel diverticulum.

History

In most cases, patients will report hematemesis, coffeeground emesis, hematochezia, or melena. The duration and frequency of these symptoms should be elicited. For hematemesis, it is important to determine whether blood was present initially or appeared after several episodes of vomiting. The latter history suggests a Mallory-Weiss tear. A history compatible with cirrhosis (chronic alcohol use, hepatitis, IV drug use) suggests varices. These patients may also have a coagulopathy, making control of hemorrhage more difficult. When bleeding has been slow but chronic, the patient may present with lightheadedness, fatigue, chest pain, or shortness of breath owing to anemia without any knowledge of GI bleeding. Patients with peptic ulcer disease may report epigastric abdominal pain related to eating. Agents that increase the risk of peptic ulcer disease include nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, and cigarettes. Elderly patients with acute hemorrhage may initially present with syncope or near-syncope.