CCM Notes
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Gastroenterology · Emergency Medicine
GI Bleeding Management
Upper vs Lower GIB · Glasgow-Blatchford Score · Resuscitation · Endoscopy Timing · PPI · Transfusion Triggers
📋 Upper vs Lower GI Bleed — Differentiation
🔴 Upper GI Bleed (UGIB)
Source proximal to Ligament of Treitz
Hematemesis (bright red or coffee-ground)
Melena (black tarry stool) — most common presentation
BUN:Cr ratio typically >20:1 (protein digestion)
Causes: PUD (40%), gastric erosions, varices (15%), Mallory-Weiss, Dieulafoy, AVM, malignancy
NG aspirate: bloody or coffee-ground → confirms UGIB
🔵 Lower GI Bleed (LGIB)
Source distal to Ligament of Treitz
Hematochezia (bright red blood per rectum)
Can also cause dark stool if slow/proximal colon
Causes: Diverticulosis (40%), angiodysplasia, ischemic colitis, IBD, neoplasm, hemorrhoids (anorectal)
Self-limited in ~80% of cases
CT angiography before colonoscopy if massive/unstable
📊 Glasgow-Blatchford Score (GBS) — Predicts Need for Intervention
| Parameter | Value | Points |
|---|
| BUN (mg/dL) | 18.2–22.4 | 2 |
| 22.4–28 | 3 |
| 28–70 | 4 |
| ≥70 | 6 |
| Hemoglobin (male) | 12–13 g/dL | 1 |
| 10–12 g/dL | 3 |
| <10 g/dL | 6 |
| Hemoglobin (female) | 10–12 g/dL | 1 |
| <10 g/dL | 6 |
| Parameter | Finding | Points |
|---|
| SBP (mmHg) | 100–109 | 1 |
| 90–99 | 2 |
| <90 | 3 |
| Pulse ≥100/min | Yes | 1 |
| Melena | Present | 1 |
| Syncope | Present | 2 |
| Hepatic disease | Yes | 2 |
| Cardiac failure | Yes | 2 |
GBS = 0 → safe outpatient discharge
GBS ≥1 → inpatient admission
GBS ≥7 → high risk; urgent endoscopy
💧 Resuscitation & Endoscopy Timing
1
2 large-bore IV lines (≥16G); GCS; secure airway if hematemesis + altered consciousness
2
IV crystalloid bolus; target MAP ≥65; type and crossmatch; CBC, coagulation, LFTs, BMP
3
Transfuse RBC when Hb <7 g/dL (Hb <8 in ACS/hemodynamic instability)
4
Correct coagulopathy: FFP if INR >1.5; platelets if <50,000; consider TXA in massive bleed
5
Endoscopy timing: Within 24h for most UGIB; within 12h for high-risk (active bleeding, hemodynamic instability, GBS ≥12)
💊 PPI Protocol & Variceal Bleed
Pre-endoscopy PPI: Pantoprazole 80 mg IV bolus then 8 mg/h infusion
Post-endoscopy (high-risk lesion): Omeprazole or pantoprazole 40 mg IV BID × 72h, then oral PPI
H. pylori testing: All peptic ulcer cases; treat if positive (triple therapy 14 days)
Variceal Bleed
Octreotide 50 mcg IV bolus → 50 mcg/h × 3–5 days
Ceftriaxone 1g IV OD × 7 days (SBP prophylaxis)
Urgent endoscopy + EVL (band ligation) or sclerotherapy
TIPS if refractory variceal hemorrhage
⚠️ Transfusion Triggers & Critical Points
●Restrictive transfusion: Target Hb ≥7 g/dL in stable UGIB (TRIGGER trial) — lower mortality than liberal strategy
●Hold NSAIDs, anticoagulants; reverse warfarin with Vitamin K IV + 4F-PCC if INR >2.5 with active bleed
●Avoid over-transfusion in varices — worsens portal HTN and re-bleeding risk
●Rockford criteria for surgery: persistent hemodynamic instability, >10 units PRBC in 24h, rebleeding × 2