Skip to content Case: Upper GI Bleed
Clinical Setup
- Presentation: 55-year-old male with 1 day of melena, one episode of hematemesis, lightheadedness on standing. History of NSAID use and alcohol use. BP 96/60, HR 116.
- Location: Emergency Department.
Optimal Order Pathway
- Immediate Orders (Minute 0–1):
- Pulse oximetry, continuous cardiac monitoring, BP q15min with orthostatics.
- 2 large-bore IVs, Normal saline 0.9% IV bolus 1000 mL stat.
- NPO stat.
- Focused Exam (Minute 1–2):
- Abdominal exam (tenderness, organomegaly), rectal exam (melena confirmation), skin exam (pallor, stigmata of liver disease).
- Diagnostics (Minute 2–5):
- CBC stat (hemoglobin/hematocrit baseline), BMP (BUN/Cr ratio), PT/INR, PTT, Type and Crossmatch.
- ECG 12-lead (tachycardia/ischemia in elderly or cardiac history).
- Nasogastric lavage is NOT routinely required for diagnosis.
- Therapeutics & Consultation (Minute 5–12):
- Pantoprazole (PPI) IV bolus + infusion.
- Transfuse packed RBCs if Hgb < 7 g/dL (or < 8 with cardiac disease) or hemodynamically unstable.
- Gastroenterology consult stat for urgent upper endoscopy (within 24 hours; sooner if unstable).
- If variceal bleed suspected (cirrhosis history): add Octreotide IV infusion and Ceftriaxone IV prophylaxis.
- Advance clock 30 min; re-examine vitals, repeat hemoglobin.
- Disposition (Minute 12–15):
- Admit to ICU if unstable/transfusing; otherwise monitored ward.
- Continue PPI; plan H. pylori testing and NSAID avoidance counseling.
- Final 2 Minutes:
- Counsel on alcohol cessation, NSAID avoidance, H. pylori eradication compliance, warning signs of rebleed.
- Schedule GI follow-up with repeat endoscopy plan as indicated.