Browse categories and answer follow-up questions to refine your symptom profile.
History
Presenting symptom and context
Symptom overview
Melena
Hematemesis
Coffee ground emesis
Hematochezia
Presyncope
Syncope
Dyspnea
Chest pain
Prior GI bleeding
OPQRST
OPQRST framework
Onset
Provocation and palliation
Quality
Region and radiation
Severity
Timing
Onset
Onset details
Time of first black stool
Number of episodes
Time of last melena
Sudden onset versus gradual
Provocation and palliation
Triggers and modifiers
NSAID exposure temporal relationship
Alcohol binge temporal relationship
Recent vomiting or retching
Recent epigastric pain pattern
Quality
Stool and emesis characteristics
Black tarry stool
Foul odor typical of melena
Red blood in emesis
Coffee ground emesis
Region and radiation
Pain location pattern
Epigastric pain
RUQ pain
Diffuse abdominal pain
Back radiation
Severity
Bleeding severity proxies
Large volume stool output
Orthostatic symptoms
Inability to ambulate
Decreased urine output
Timing
Temporal pattern
Continuous bleeding
Intermittent bleeding
No further bleeding since arrival
Recent endoscopy timing
Associated symptoms
Associated symptom cluster
Lightheadedness
Weakness
Palpitations
Fever
Abdominal pain
Nausea
Vomiting
Dysphagia
Weight loss
Jaundice
Confusion
Bleeding history details
Bleeding characterization
Anticoagulant use and last dose timing
Antiplatelet use and last dose timing
Known liver disease and variceal history
Known peptic ulcer disease history
Prior endoscopic hemostasis history
Prior transfusion reactions
Baseline and functional status
Baseline status
Baseline hemoglobin if known
Baseline blood pressure
Baseline exercise tolerance
Home supports and supervision
Alarm Features
Immediate resuscitation triggers
High risk physiology
Systolic blood pressure less than 90 mmHg
MAP less than 65 mmHg
Heart rate greater than 120
Shock index greater than 1
Altered mental status
Ongoing hematemesis
Massive melena with hemodynamic change
Airway risk
Aspiration and airway compromise
Active hematemesis with inability to protect airway
Persistent vomiting with declining mental status
Hypoxemia on room air
High risk historical features
High risk history
Cirrhosis with suspected variceal bleed
Recent upper GI surgery
Known aortoenteric graft
Recent endoscopic intervention with rebleeding
High risk exam findings
High risk exam
Cool clammy skin
Delayed capillary refill
Marked orthostasis
Peritonitis
Time critical escalation
Escalation logic
If hypotension or active hematemesis then resuscitation bay
If suspected variceal bleed then urgent GI and ICU involvement
If refractory shock then massive transfusion pathway per local protocol dependent
Medications
Hemorrhage relevant medications
Medication exposures
Anticoagulants
Antiplatelets
NSAIDs
Corticosteroids
SSRIs and SNRIs
Herbal supplements with bleeding risk
Anticoagulant specifics
Anticoagulant details
Warfarin
Apixaban
Rivaroxaban
Dabigatran
Edoxaban
Heparin
LMWH
Antiplatelet specifics
Antiplatelet details
Aspirin
Clopidogrel
Prasugrel
Ticagrelor
Recent medication changes
Recent changes
New anticoagulant start within 30 days
Dose increase within 30 days
Missed doses with rebound thrombosis risk context
Contraindications and interaction traps
Therapy conflicts
QT prolonging antiemetics with baseline QTc prolongation
PPI interaction considerations with clopidogrel local practice dependent
Renal impairment effects on DOAC clearance
Diet
Intake and hydration
Intake pattern
Poor oral intake
Recent fasting
Reduced fluid intake
Persistent vomiting limiting intake
Alcohol exposure
Alcohol pattern
Heavy daily use
Recent binge
Prior alcohol withdrawal history
Dietary contributors
Confounders of stool color
Iron supplements
Bismuth subsalicylate
Dark foods and dyes
Review of Systems
Gastrointestinal
GI symptoms
Abdominal pain
Nausea
Vomiting
Dysphagia
Odynophagia
Early satiety
Diarrhea
Constipation
Cardiopulmonary
Cardiorespiratory symptoms
Dyspnea
Chest pain
Palpitations
Orthopnea
Cough
Neurologic
Neurologic symptoms
Syncope
Presyncope
Confusion
Focal deficits
Infectious and systemic
Systemic symptoms
Fever
Chills
Unintentional weight loss
Night sweats
Collateral History and Family History
Collateral sources
Collateral and reliability
Family report
EMS report
Prior records
Pharmacy fill history
Family history
Family history relevant
Colorectal cancer family history
Upper GI malignancy family history
Bleeding disorders family history
Exposure context
Household and contacts
Sick contacts
Similar GI illness in household
Support and follow up reliability
Disposition supports
Transportation access
Ability to return promptly if worse
Risk Factors
Peptic ulcer and mucosal injury risks
Ulcer risk profile
NSAID use
Helicobacter pylori history
Prior ulcer bleed
Smoking
Portal hypertension risks
Variceal risk profile
Cirrhosis
Prior variceal bleeding
Ascites
Thrombocytopenia history
Malignancy risks
Cancer risk profile
Weight loss
Dysphagia
Early satiety
Older age risk
Vascular and surgical risks
Vascular and anastomotic risks
Aortic graft history
Prior GI surgery with anastomosis
Radiation exposure history
Bleeding and thrombosis balance
Hemostasis modifiers
Anticoagulation indication
Recent VTE history
Mechanical valve history
Recent coronary stent history
Differential Diagnosis
Life threatening
Cannot miss causes
Variceal hemorrhage (I85.01)
Cirrhosis stigmata
Hemodynamic instability
Bleeding peptic ulcer (K27.4)
NSAID exposure
Epigastric pain history
Aortoenteric fistula (I77.2)
Prior aortic graft
Sentinel bleed pattern
Upper GI malignancy bleed (C16.9)
Weight loss
Dysphagia
Severe esophagitis or ulceration (K20.9)
Odynophagia
Immunocompromised status
Common
Common causes
Gastric ulcer (K25.4)
NSAIDs
H pylori history
Duodenal ulcer (K26.4)
Nocturnal pain
Relief with food history
Erosive gastritis (K29.60)
Alcohol use
NSAIDs
Mallory Weiss tear (K22.6)
Retching before bleed
Hematemesis prominence
Less common
Less common causes
Dieulafoy lesion (K31.82)
Sudden large volume bleed
Minimal prodromal symptoms
Gastric antral vascular ectasia (K31.819)
Chronic anemia pattern
Cirrhosis or systemic sclerosis association
Angiodysplasia (K55.20)
Recurrent bleeding episodes
CKD association
Hemobilia (K83.1)
Recent hepatobiliary procedure
RUQ pain and jaundice pattern
Hemosuccus pancreaticus (K86.89)
Pancreatitis history
Intermittent bleeding pattern
Mimics and pitfalls
Mimics
Iron or bismuth related dark stool
Normal vital signs
No anemia trend
Epistaxis with swallowed blood
Nasal bleeding history
Oropharyngeal blood
Past Medical History
GI history
Prior GI disease
Peptic ulcer disease
Prior GI bleeding admission
GERD
Known esophageal varices
Liver disease history
Chronic liver disease
Cirrhosis etiology
Prior ascites or encephalopathy
Prior band ligation
Cardiovascular and thrombotic history
Anticoagulation indication
Atrial fibrillation (I48.91)
VTE history (I82.90)
Mechanical valve (Z95.2)
Recent PCI or stent (Z95.5)
Surgical and device history
Procedures and devices
Aortic graft history
Bariatric surgery
Feeding tube
Dialysis access
Baseline function
Baseline functional status
Independent ADLs
Frailty features
Baseline cognitive impairment
Physical Exam
General and vitals
Global assessment
Mental status and perfusion
Respiratory distress
Temperature pattern
Orthostatic vitals if stable
Hemodynamics and volume status
Shock and volume signs
Capillary refill
Skin temperature
JVP estimate
Peripheral edema
HEENT and airway
Upper airway sources
Epistaxis evidence
Oropharyngeal blood
Cardiovascular
Cardiac exam
Tachycardia pattern
New murmur
Signs of ischemia with anemia context
Pulmonary
Lung exam
Aspiration signs
Hypoxia pattern
Abdominal
Abdominal exam
Epigastric tenderness
Peritonitis
Hepatomegaly
Ascites
Rectal and stool assessment
Lower exam cues
Melena on rectal exam
Hematochezia
Masses or hemorrhoids
Stigmata of chronic liver disease
Portal hypertension clues
Jaundice
Spider angiomata
Asterixis
Caput medusae
Lab Studies
Initial core labs
Baseline evaluation
CBC with platelets
Electrolytes
Creatinine and urea
Liver enzymes
Bilirubin
INR
aPTT
Type and blood product preparation
Transfusion readiness
Type and screen
Crossmatch if active bleed
Antibody history if known
Perfusion and end organ markers
Shock markers
Venous lactate
Blood gas if respiratory compromise
Interpretation pearls
Key interpretation
Urea elevation supportive of upper GI source
Hemoglobin may lag early in acute bleed
Thrombocytopenia suggests portal hypertension or consumption
Serial trending
Recheck timing
Repeat hemoglobin in 4 to 6 hours if ongoing concern
More frequent checks if active bleeding or shock
Imaging
Scoring Systems
Risk stratification tools
Glasgow Blatchford Score
Pre endoscopy triage and disposition
Low risk pathway consideration when score equals 0 to 1 local protocol dependent
AIMS65
In hospital mortality risk
Useful when albumin and INR available
Rockall score
Post endoscopy rebleeding and mortality risk
Limited use pre endoscopy
MRI
MRI role limited
Not first line for acute UGIB
Consideration for alternative diagnoses when stable
CT
CT and CTA use
CTA abdomen pelvis for ongoing brisk bleeding with nondiagnostic endoscopy or unavailable endoscopy
Aortoenteric fistula evaluation in patients with aortic graft and GI bleed
Contrast nephropathy risk assessment
Contrast allergy considerations
Ultrasound
POCUS adjuncts
IVC assessment for volume status support
Focused cardiac ultrasound for shock phenotype support
Ascites identification in cirrhosis
Limitations in localizing intraluminal bleeding
Special Tests
Bedside tests
Bedside diagnostics
Rectal exam confirmation of melena
Stool guaiac limitations
Orthostatic vitals if safe
Nasogastric tube considerations
NG tube utility and limits
Bloody aspirate supports upper source
Clear aspirate does not exclude duodenal bleeding
Contraindications
Suspected esophageal varices relative risk
Recent esophageal surgery
Endoscopy
Upper endoscopy
Diagnostic and therapeutic standard
Timing within 24 hours for most admitted patients
Earlier endoscopy for ongoing bleeding or hemodynamic instability
H pylori testing
Etiology evaluation
Stool antigen testing when stable
Urea breath testing outpatient pathway when appropriate
False negatives possible with PPI or antibiotics exposure
ECG
Indications in UGIB
ECG triggers
Chest pain
Dyspnea
Syncope
Older age with anemia
High risk findings
Concerning patterns
ST depression consistent with demand ischemia
New ischemic changes
Rapid atrial fibrillation
Serial ECG logic
Repeat strategy
Repeat if new chest pain during resuscitation
Repeat with rising troponin or ongoing hypotension
Assessment
Working diagnosis framing
Upper gastrointestinal bleeding with melena (K92.1)
Suspected source category
Non variceal suspected
Variceal suspected
Severity tier
Stable
Transient responder
Persistent shock
Risk stratification
Risk summary
Hemodynamic instability present
Ongoing overt bleeding present
Anticoagulation present
Cirrhosis present
Complications to rule out
Complication screen
Hemorrhagic shock
Myocardial ischemia from anemia
Aspiration pneumonitis
Acute kidney injury
Diagnostic uncertainty
Alternate considerations
Dark stool mimic exposure present
Lower GI bleed with rapid transit possible
Non GI source swallowed blood possible
Plan
First 5 minutes
Immediate stabilization
Airway and aspiration precautions
Oxygen for hypoxemia
Cardiac monitor
Two large bore IVs
Rapid blood draw with type and screen
Activate massive transfusion pathway per local protocol dependent if severe shock
Resuscitation and transfusion
Hemodynamic support
Balanced transfusion strategy if massive bleeding per local protocol dependent
Packed RBC transfusion threshold
Hemoglobin less than 70 g/L in most patients
Higher threshold in active cardiac ischemia or severe comorbidity individualized
Platelet transfusion considerations
Severe thrombocytopenia with active bleeding
Planned endoscopic therapy threshold per local protocol dependent
Acid suppression and hemostatic pharmacotherapy
Medication therapy
PPI IV bolus then infusion or intermittent high dose per local protocol dependent
Pantoprazole IV 80 mg once
Then 8 mg per hour infusion
Alternative pantoprazole IV 40 mg every 12 hours
If suspected variceal bleeding then vasoactive therapy
Octreotide IV 50 mcg bolus
Then 50 mcg per hour infusion
If suspected variceal bleeding then antibiotics
Ceftriaxone IV 1 g daily
Duration typically up to 7 days per GI plan
Anticoagulation and antiplatelet reversal
Reversal strategy
Warfarin associated bleeding
Vitamin K IV 10 mg
PCC dosing per product and INR local protocol dependent
Dabigatran associated bleeding
Idarucizumab IV 5 g
Factor Xa inhibitor associated bleeding
PCC local protocol dependent
Andexanet alfa availability local protocol dependent
Heparin associated bleeding
Protamine dosing per heparin timing
Diagnostic sequencing
Testing flow
Labs and type and screen early
ECG if symptoms or high risk
Endoscopy planning after stabilization
CTA consideration if ongoing bleed and endoscopy delayed or nondiagnostic
Consultation
Specialist involvement
Gastroenterology early for endoscopy planning
ICU for shock or high risk scores
Surgery and vascular surgery if aortoenteric fistula concern
Reassessment loop
Repeat checks
Recheck vitals every 15 to 30 minutes during active resuscitation
Repeat abdominal exam for peritonitis evolution
Monitor for ongoing bleeding output
Repeat hemoglobin trend based on stability
Disposition
ICU criteria
ICU level care indicators
Ongoing hemodynamic instability
Need for vasopressors
Ongoing massive transfusion requirement
High risk variceal bleed with active hemorrhage
Inpatient admission criteria
Admission indicators
Transfusion requirement
Active bleeding within ED course
Significant comorbidity
Anticoagulation with reversal needs
Moderate to high risk scores
Observation pathway
Observation candidates local protocol dependent
Stable vitals after ED course
No ongoing bleeding observed
Hemoglobin stable on repeat check
Discharge criteria
Safe discharge requirements
Low risk score pathway local protocol dependent
No ongoing bleeding
Stable vital signs
Reliable follow up within 24 to 72 hours
Clear return precautions understood
Transfer criteria
Transfer triggers
No endoscopy capability
Ongoing bleeding requiring intervention
Suspected aortoenteric fistula requiring vascular surgery
Discharge Instructions
Copy discharge instructions
Patient instructions
You have signs of bleeding in your stomach or upper intestine that can cause black stools
Return to the emergency department right away if you vomit blood or have black stools again
Return right away for fainting, severe weakness, chest pain, trouble breathing, or confusion
Avoid NSAIDs such as ibuprofen or naproxen unless a clinician tells you otherwise
Take your acid reducing medicine exactly as prescribed
Avoid alcohol until you are cleared by your clinician
Follow up within 24 to 72 hours as arranged for further testing and possible endoscopy
If you take blood thinners do not restart them unless you were told to do so
References
Guidelines and decision tools
Key references
American College of Gastroenterology guideline for upper gastrointestinal and ulcer bleeding 2021
Baveno consensus guidance on portal hypertension and variceal bleeding latest update local protocol dependent
European Society of Gastrointestinal Endoscopy guideline non variceal upper GI hemorrhage 2021 update
Glasgow Blatchford Score derivation and validation studies
AIMS65 derivation and validation studies
Rockall score derivation and validation studies
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.