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Information ⬇

  1. Hematemesis:Vomiting of blood or altered blood (“coffee grounds”) indicates bleeding proximal to ligament of Treitz.
  2. Melena: Altered (black) blood per rectum (>100-mL blood required for one melenic stool) usually indicates bleeding proximal to ligament of Treitz but may be as distal as ascending colon; pseudomelena may be caused by ingestion of iron, bismuth, licorice, beets, blueberries, and charcoal.
  3. Hematochezia: Bright red or maroon rectal bleeding usually implies bleeding beyond ligament of Treitz but may be due to rapid upper GI bleeding (>1000 mL).
  4. Positive fecal occult blood test with or without iron deficiency.
  5. Symptoms of blood loss: e.g., light-headedness or shortness of breath.

Hemodynamic Changes

Orthostatic drop in bp >10 mmHg usually indicates >20% reduction in blood volume (± syncope, light-headedness, nausea, sweating, thirst).

Shock

BP <100 mmHg systolic usually indicates <30% reduction in blood volume (± pallor, cool skin).

Laboratory Changes

Hematocrit may not reflect extent of blood loss because of delayed equilibration with extravascular fluid. Mild leukocytosis and thrombocytosis. Elevated blood urea nitrogen is common in upper GI bleeding.

Adverse Prognostic Signs

Age >60 years, associated illnesses, coagulopathy, immunosuppression, presentation with shock, rebleeding, onset of bleeding in hospital, variceal bleeding, endoscopic stigmata of recent bleeding (e.g., “visible vessel” in ulcer base [see next]).

Outline ⬆

Section 3. Common Patient Presentations