Intermediate•7 min read•High Yield

Gastrointestinal Bleeding - CCS Case Guide

Key Takeaway: Gastrointestinal bleeding is a common emergency requiring rapid assessment of hemodynamic stability, resuscitation, and identification of the bleeding source. Upper GI bleeds are more common and often managed with PPI and endoscopy within 24 hours.

Gastrointestinal bleeding is a common emergency requiring rapid assessment of hemodynamic stability, resuscitation, and identification of the bleeding source. Upper GI bleeds are more common and often managed with PPI and endoscopy within 24 hours. CCS cases test appropriate resuscitation and timely GI consultation.

Recognizing the GI Bleed Presentation

  • History: Hematemesis, coffee-ground emesis, melena, or hematochezia; history of NSAID use, alcohol use, liver disease, prior GI bleed, or anticoagulant use
  • Physical Exam: Pallor, tachycardia, hypotension, abdominal tenderness, rectal exam with melena or bright red blood, stigmata of chronic liver disease (spider angiomata, ascites)
  • Vital Signs: Tachycardia, orthostatic hypotension, possible frank hypotension in severe hemorrhage

Immediate Actions (First 5 Minutes)

These orders should be placed immediately — timing is scored:

Critical First Orders

  • ✓ Two large-bore IV access (16-18 gauge)
  • ✓ Type and crossmatch
  • ✓ IV crystalloid bolus
  • ✓ CBC, BMP, coagulation studies, hepatic panel
  • ✓ Transfuse pRBCs if hemoglobin < 7 g/dL (or < 8 if cardiac disease)
  • ✓ IV PPI (pantoprazole 80 mg bolus then 8 mg/hr drip) if upper GI bleed suspected

Complete Workup

After initial stabilization, complete the diagnostic workup:

  • CBC (hemoglobin may not drop immediately)
  • BMP (BUN:creatinine ratio elevated in upper GI bleed)
  • Coagulation studies (PT/INR, PTT)
  • Hepatic panel
  • Type and screen / crossmatch
  • Lactate
  • Glasgow-Blatchford score (risk stratification)
  • EGD within 24 hours (or urgent if hemodynamically unstable)
  • Colonoscopy (if lower GI bleed, after bowel prep if stable)
  • CT angiography if brisk bleeding and endoscopy not feasible

Treatment

Resuscitation

  • IV crystalloid bolus (NS or LR)
  • Transfuse pRBCs for Hgb < 7 (restrictive threshold)
  • Correct coagulopathy (FFP, vitamin K, platelets as needed)
  • Hold anticoagulants and antiplatelets

Upper GI Bleed

  • IV pantoprazole 80 mg bolus then 8 mg/hr continuous infusion
  • EGD within 24 hours (within 12 hours if high-risk features)
  • Endoscopic therapy (epinephrine injection, thermal coagulation, clips)
  • IV octreotide if variceal bleed suspected (50 mcg bolus then 50 mcg/hr)
  • Ceftriaxone 1 g IV daily for SBP prophylaxis in cirrhotics

Lower GI Bleed

  • Colonoscopy after hemodynamic stabilization and bowel prep
  • CT angiography if brisk bleeding
  • IR embolization or surgery if endoscopy fails

Variceal Bleed

  • Octreotide drip
  • Ceftriaxone for SBP prophylaxis
  • Urgent EGD with band ligation
  • Balloon tamponade (Blakemore tube) as bridge if uncontrolled
  • Consider TIPS if refractory

Common Pitfalls

Scoring Tip: These are the most commonly missed actions for GI Bleed cases.

  • Relying on initial hemoglobin (may not reflect acute blood loss)
  • Forgetting type and crossmatch early
  • Not starting IV PPI before endoscopy in suspected upper GI bleed
  • Over-transfusing (liberal threshold worsens outcomes in variceal bleeds)
  • Failing to discontinue NSAIDs and anticoagulants
  • Not giving octreotide and antibiotics in suspected variceal bleed

Disposition

  • ICU if hemodynamically unstable or requiring active transfusion
  • Telemetry floor for stable GI bleed with monitoring
  • Discharge when hemodynamically stable, hemoglobin trending up, and PO PPI started
  • GI follow-up and H. pylori testing if peptic ulcer disease

Key Orders Checklist

  • ☐ Type and crossmatch
  • ☐ IV pantoprazole drip
  • ☐ CBC every 6-8 hours
  • ☐ GI consult for endoscopy
  • ☐ NPO for EGD
  • ☐ Transfuse pRBCs as needed
  • ☐ Hold anticoagulants

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