Upper Gastrointestinal Bleeding Symptoms (melena)APPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

500 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Abdominal Distension Abdominal Pain, Undifferentiated Acute Abdominal Pain (general)Suspected Incarcerated Or Strangulated Hernia Pancreatitis Concern Biliary Colic And Cholecystitis Concern Appendicitis Concern Diverticulitis Concern Rectal Pain And Anorectal Complaints Dysphagia And Food Bolus Impaction Foreign Body Ingestion Refractory Vomiting And Recurrent Vomiting Syndromes Cannabis Associated Hyperemesis Upper Gastrointestinal Bleeding Symptoms (melena)Lower Gastrointestinal Bleeding And Hematochezia Constipation And Obstipation Diarrhea Acute Hepatitis And Jaundice Concern Right Upper Quadrant Pain Epigastric Pain Left Upper Quadrant Pain Right Lower Quadrant Pain Left Lower Quadrant Pain Suprapubic Pain

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx71

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

02Alarm Features/alarm26

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

03Medications/meds28

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

04Diet/diet13

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

05Review of Systems/ros25

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

06Collateral History and Family History/chafh15

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

07Risk Factors/rf24

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

08Differential Diagnosis/ddx52

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

09Past Medical History/pmh23

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

10Physical Exam/exam34

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

11Lab Studies/labs22

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

12Imaging/img23

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 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

13Special Tests/spec18

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

14ECG/ecg12

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

15Assessment/ax22

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

16Plan/plan51

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

17Disposition/dispo25

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

18Discharge Instructions/di9

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

19References/r7

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Upper Gastrointestinal Bleeding Symptoms (melena)APPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

500 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx71

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

02Alarm Features/alarm26

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

03Medications/meds28

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

04Diet/diet13

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

05Review of Systems/ros25

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

06Collateral History and Family History/chafh15

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

07Risk Factors/rf24

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

08Differential Diagnosis/ddx52

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

09Past Medical History/pmh23

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

10Physical Exam/exam34

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

11Lab Studies/labs22

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

12Imaging/img23

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 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

13Special Tests/spec18

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

14ECG/ecg12

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

15Assessment/ax22

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

16Plan/plan51

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

17Disposition/dispo25

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

18Discharge Instructions/di9

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

19References/r7

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.