GI Bleeding (Upper and Lower)
2
Large-Bore IVs
First priority after recognition
50-100 mL
Melena Threshold
Minimum blood for black stool
8+ hours
Melena Onset
Time for blood to transit GI tract
Upper vs Lower GI Bleeding
the ligament of Treitz is the dividing lineUpper GI
Above the ligament of Treitz
- Presentation Hematemesis, coffee-ground emesis, melena
- Common causes Peptic ulcer disease, esophageal varices, Mallory-Weiss tear, gastritis
- Diagnosis EGD (esophagogastroduodenoscopy)
- BUN/Cr ratio Often elevated (digested blood increases BUN)
Lower GI
Below the ligament of Treitz
- Presentation Hematochezia (bright red blood per rectum)
- Common causes Diverticulosis (#1), angiodysplasia, colorectal cancer, hemorrhoids
- Diagnosis Colonoscopy (once stabilized)
- Note Most lower GI bleeds stop spontaneously
Variceal Bleeding
Esophageal varices develop from portal hypertension (usually cirrhosis). These thin-walled, dilated veins can rupture catastrophically.
Hemodynamic stabilization (two large-bore IVs, type and cross, transfuse)
IV octreotide (reduces portal pressure and splanchnic blood flow)
Emergent EGD with band ligation or sclerotherapy
If refractory to endoscopic treatment, balloon tamponade (Blakemore or Minnesota tube) as a bridge
TIPS (transjugular intrahepatic portosystemic shunt) for recurrent or refractory variceal bleeding
General Management Priorities
Hemodynamic instability takes priority over diagnostic workup. Stabilize first, then scope. A patient who is hypotensive and tachycardic needs IVs, fluids, and blood products before any scope is wheeled in.
Two large-bore (16-18g) peripheral IVs immediately
Type and crossmatch, CBC, coags, BMP, lactate
Crystalloid resuscitation, transfuse pRBCs if Hgb <7 (or <9 in active bleeding with instability)
NPO status, continuous monitoring, Foley for strict I&O
PPI infusion for suspected upper GI (peptic ulcer)
Hold anticoagulants, reverse if indicated
Key Values to Memorize
Melena = 50-100 mL blood
Melena onset 8+ hours
Transfuse Hgb <7 (stable)
Two 16-18g large-bore IVs
Octreotide for varices
TIPS for recurrent variceal
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Practice CCRN QuestionsExam Traps
Stabilize BEFORE scope
Hemodynamic instability takes priority over diagnostic workup. Two large-bore IVs, type and crossmatch, fluid resuscitation, and blood products come before endoscopy. The exam will present an unstable patient and ask what to do first. The answer is never "schedule EGD."
Avoid NG tube placement in suspected variceal bleeding
Inserting a nasogastric tube in a patient with suspected esophageal varices can trigger massive hemorrhage by irritating or rupturing fragile variceal tissue. The risks outweigh the diagnostic benefit.
Hematochezia in an unstable patient may be a massive upper GI bleed
Bright red blood per rectum typically suggests lower GI bleeding. But when a patient is hemodynamically unstable with hematochezia, blood may be transiting so rapidly from an upper source that it does not have time to turn black. Always consider a massive upper bleed.
Melena requires at least 50-100 mL of blood
It takes a minimum of 50-100 mL of blood in the GI tract to produce melena (black, tarry stool). The blood must remain in the GI tract for at least 8 hours for bacterial degradation to occur. Melena can persist for up to 5 days after bleeding stops.
Hematochezia Warning
Hematochezia (bright red blood) in a hemodynamically UNSTABLE patient? Could be a massive UPPER GI bleed, not just lower. Do not assume.
Variceal Bleeding Protocol
Variceal bleeding protocol is octreotide + emergent EGD. If refractory, balloon tamponade. TIPS for recurrent episodes.
Think of a leak near the top of a dam. Water (blood) flows down a long river (the GI tract) before exiting at the bottom. By the time it exits, it has changed color (melena = black, tarry). Common causes are peptic ulcers, esophageal varices, and Mallory-Weiss tears.
A leak near the bottom of the dam means blood exits quickly and looks fresh (hematochezia = bright red). The ligament of Treitz divides upper from lower. Common causes are diverticulosis, hemorrhoids, colorectal cancer, and angiodysplasia.
A massive crack near the top of the dam can send water rushing through so fast it still looks fresh at the bottom. That is why bright red blood in an unstable patient might actually be an upper bleed. Volume and speed matter.
No matter where the leak is, your first job is to prevent the valley from flooding (hemodynamic stabilization). Plug the dam later (endoscopy). Stabilize first, scope second.
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