01Approach to the Critical Patient/attcp42

Initial triage and risk

›Presentation phenotypes

›Uncomplicated dyspepsia without bleeding or peritonitis

›Upper gastrointestinal bleeding phenotype

›Perforation phenotype

›Gastric outlet obstruction phenotype

›Immediate instability triggers

›SBP < 90 mmHg

›HR > 120 beats/min

›Altered mental status

›Ongoing hematemesis

›Peritoneal signs

›Early escalation

›Resuscitation bay for shock, active hematemesis, peritonitis

›Gastroenterology consult for suspected high risk bleeding

›Surgery consult for suspected perforation or obstruction

Resuscitation for suspected bleeding ulcer

›Hemodynamic support

›Two large bore IV lines or intraosseous access if needed

›Continuous monitoring and frequent reassessment

›Crystalloid only as bridge to blood products in hemorrhagic shock

›Blood products strategy

›Type and screen with crossmatch

›Transfusion threshold hemoglobin < 70 g/L for most stable patients

›Transfusion threshold hemoglobin < 80 g/L for active ischemia or significant cardiovascular disease

›Massive transfusion protocol for ongoing shock with suspected life threatening hemorrhage

›Coagulopathy and antithrombotics

›Anticoagulant history and timing of last dose

02History/hx48

Symptom characterization

›Dyspepsia pattern

›Epigastric pain

›Postprandial pain

›Nocturnal pain

›Relief with food or antacids

›Bleeding symptoms

›Hematemesis

›Coffee ground emesis

›Melena

›Hematochezia with hemodynamic compromise

›Presyncope or syncope

›Perforation and obstruction symptoms

›Sudden severe generalized abdominal pain

›Shoulder pain with diaphragmatic irritation

›Persistent nonbilious vomiting

›Early satiety

›Unintentional weight loss

Risk factors and exposures

›Ulcer risk drivers

›NSAID use

›Aspirin use

›Anticoagulant use

›P2Y12 inhibitor use

›Systemic glucocorticoid use with NSAID

›Tobacco use

›Heavy alcohol use

›Helicobacter pylori risk context

03Physical Exam/exam24

Hemodynamic and general assessment

›Perfusion status

›Mental status

›Skin temperature and diaphoresis

›Capillary refill

›Vital sign patterns

›Orthostatic vitals when safe

›Tachycardia out of proportion to pain

›Hypotension

›Anemia and bleeding stigmata

›Conjunctival pallor

›Delayed capillary refill

›Melena on stool assessment when indicated

Abdominal and focused findings

›Abdominal exam domains

›Epigastric tenderness

›Guarding

›Rebound tenderness

›Rigidity

›Distension

›Complication signatures

›Peritonitis signs suggesting perforation

›Succussion splash suggesting gastric outlet obstruction

›Extra abdominal exam for contributors

›Stigmata of chronic liver disease

›Cardiac exam for heart failure in risk scoring

04Differential Diagnosis/ddx21

Life threatening and time sensitive

›Upper GI bleeding sources

›Bleeding peptic ulcer disease ICD-10 K27.4

›Gastric ulcer with hemorrhage ICD-10 K25.4

›Duodenal ulcer with hemorrhage ICD-10 K26.4

›Mallory Weiss tear ICD-10 K22.6

›Esophageal varices with bleeding ICD-10 I85.01

›Perforation sources

›Perforated gastric ulcer ICD-10 K25.5

›Perforated duodenal ulcer ICD-10 K26.5

›Perforated viscus unspecified ICD-10 K63.1

›Cardiac mimic

›Acute coronary syndrome ICD-10 I21.9

Common mimics and overlapping syndromes

›Upper abdominal pain causes

›Gastroesophageal reflux disease ICD-10 K21.9

›Gastritis and duodenitis ICD-10 K29.7

›Functional dyspepsia ICD-10 K30

›Acute pancreatitis ICD-10 K85.9

›Biliary colic and cholecystitis ICD-10 K80.2 and K81.0

›Hepatitis ICD-10 K75.9

›Mesenteric ischemia ICD-10 K55.9

›Abdominal aortic aneurysm ICD-10 I71.4

05Laboratory Tests/lt40

Bleeding and anemia evaluation

›Hematology and perfusion

›Complete blood count for anemia severity

›Hemoglobin trend for ongoing bleeding

›Platelet count for hemostasis planning

›Basic metabolic panel for renal function and resuscitation

›Urea elevation supporting upper GI bleed physiology

›Creatinine for dosing and risk assessment

›Coagulation profile for anticoagulation effect and liver disease

›INR for warfarin effect or hepatic dysfunction

›aPTT when heparin exposure possible

›Type and screen with crossmatch for active bleeding

›Rh type and antibody screen

›Crossmatched units for unstable patients

›Venous blood gas with lactate for shock physiology

›Lactate elevation supporting hypoperfusion

›pH for severe metabolic derangement

Alternative diagnosis labs

›Hepatobiliary and pancreatic

›Liver enzymes when biliary or hepatic disease in differential

›AST and ALT pattern

›Bilirubin for obstruction

›Lipase for pancreatitis evaluation

›Marked elevation supporting pancreatitis over ulcer pain

›Pregnancy status when relevant

›Urine or serum pregnancy test

›Medication safety implications

›Ectopic pregnancy redirection when pain atypical

06Diagnostic Tests/dt71

Scoring Systems

›Glasgow Blatchford Score for upper GI bleeding triage

›Blood urea nitrogen points

›6.5 to 7.9 mmol/L 2 points

›8.0 to 9.9 mmol/L 3 points

›10.0 to 24.9 mmol/L 4 points

›25.0 mmol/L or higher 6 points

›Hemoglobin points male

›120 to 129 g/L 1 point

›100 to 119 g/L 3 points

›Less than 100 g/L 6 points

›Hemoglobin points female

›100 to 119 g/L 1 point

›Less than 100 g/L 6 points

›Systolic blood pressure points

›100 to 109 mmHg 1 point

›90 to 99 mmHg 2 points

›Less than 90 mmHg 3 points

›Other clinical variables

›Pulse 100 beats/min or higher 1 point

›Melena 1 point

›Syncope 2 points

›Hepatic disease 2 points

›Heart failure 2 points

›Interpretation anchors

›Score 0 to 1 low risk candidate for outpatient management with reliable follow up

›Higher scores associated with need for intervention and admission

07Disposition/dispo27

Admission and level of care

›ICU or monitored setting

›Hemodynamic instability

›Ongoing hematemesis or persistent melena with tachycardia

›Recurrent bleeding after initial stabilization

›Significant comorbidity with limited reserve

›Inpatient ward admission

›Moderate risk upper GI bleeding requiring endoscopy

›New anemia requiring transfusion but stable after resuscitation

›Intractable vomiting or dehydration

›Suspected gastric outlet obstruction

›Transfer criteria

›No endoscopy capability and significant bleed risk

›Need for interventional radiology embolization not available locally

›Need for emergent surgery with limited local resources

Discharge criteria and follow up

›Low risk bleeding pathway

›Glasgow Blatchford Score 0 to 1

›No ongoing bleeding

›Normal mental status and stable vitals

›Reliable access to return care

›Uncomplicated dyspepsia pathway

›No alarm features

›Pain controlled with oral therapy

›Outpatient H pylori testing plan

›Follow up within 2 to 4 weeks

›Post endoscopy low risk lesions

›Clean base ulcer or flat spot without high risk stigmata

08Treatment/t74

Acid suppression and mucosal protection

›Proton pump inhibitor core therapy

›Pantoprazole PO 40 mg daily for uncomplicated ulcer healing

›Typical duration duodenal ulcer 4 weeks

›Typical duration gastric ulcer 8 weeks

›Pantoprazole PO 40 mg twice daily for high risk bleeding ulcer after endoscopy

›Continue twice daily for 14 days after index endoscopy

›Step down to daily dosing to complete healing course

›High dose IV proton pump inhibitor for bleeding ulcer

›Pantoprazole IV 80 mg bolus then 8 mg/hour infusion

›Duration 72 hours after endoscopic hemostasis

›Alternative high dose intermittent regimen

›Pantoprazole IV 40 mg every 12 hours for 72 hours when infusion not feasible

›Sucralfate adjunct when needed

›Sucralfate 1 g PO four times daily

›Drug interaction spacing at least 2 hours from other meds

›H2 receptor antagonist options

›Famotidine 20 mg PO twice daily

›Reduced efficacy vs proton pump inhibitor for ulcer healing

Endoscopic and procedural hemostasis for bleeding ulcers

›Endoscopic therapy principles

›Combination therapy for active bleeding or visible vessel

›Injection therapy plus thermal or mechanical therapy

›Clip therapy for visible vessel

›Thermal coagulation for oozing bleeding

›Recurrent bleeding pathway

›Repeat endoscopy for rebleeding after initial hemostasis

›Transcatheter arterial embolization when repeat endoscopy fails or not feasible

›Surgery when embolization unavailable or unsuccessful

Helicobacter pylori eradication and test of cure

›Treatment naive empiric first line when susceptibility unknown

›Optimized bismuth quadruple therapy 14 days

›Proton pump inhibitor standard dose twice daily

›Bismuth subsalicylate 524 mg four times daily

›Tetracycline 500 mg four times daily

›Metronidazole 500 mg three times daily

›Alternatives when bismuth quadruple not feasible

›Rifabutin triple therapy 14 days

›Omeprazole 40 mg three times daily

›Amoxicillin 1000 mg three times daily

›Rifabutin 50 mg three times daily

›Vonoprazan amoxicillin dual therapy 14 days

›Vonoprazan 20 mg twice daily

›Amoxicillin 1000 mg three times daily

›Penicillin allergy considerations

›Bismuth quadruple therapy preferred when tetracycline acceptable

›Formal allergy evaluation or test dosing pathway when history unclear

›Test of cure requirements

›Urea breath test or stool antigen test at least 4 weeks after antibiotics

›Proton pump inhibitor held at least 14 days before test of cure

›Bismuth held at least 28 days before test of cure

›Post eradication recurrence prevention

›Confirmed eradication reduces ulcer recurrence and rebleeding risk

›Avoid empiric repeat antibiotics without confirmation of persistent infection

NSAID and antiplatelet associated ulcer management

›NSAID cessation strategy

›Stop nonselective NSAID when possible

›Switch to lowest effective dose and shortest duration if must continue

›Gastroprotection when NSAID required

›Proton pump inhibitor co-therapy daily

›COX-2 selective NSAID plus proton pump inhibitor for very high risk patients

›Misoprostol 200 mcg four times daily as alternative when proton pump inhibitor not tolerated

›Aspirin management in ulcer bleeding

›Continue aspirin for primary prevention only after reassessing net benefit

›Resume aspirin early after hemostasis for secondary cardiovascular prevention

Perforation and gastric outlet obstruction treatment

›Perforation management bundle

›Initiate broad spectrum antibiotics

›Piperacillin tazobactam 4.5 g IV every 6 hours

›Alternative ceftriaxone 2 g IV daily plus metronidazole 500 mg IV every 8 hours

›Proton pump inhibitor IV therapy

›Pantoprazole IV 40 mg every 12 hours

›Early surgery consultation for operative source control

›Gastric outlet obstruction management bundle

›Nasogastric decompression when significant vomiting or distension

›IV fluids and electrolyte correction

›Endoscopy to evaluate obstructing ulcer vs malignancy

›H pylori eradication when present

›Surgery consultation for persistent obstruction or malignancy concern

09Special Populations/sp32

Pregnancy

›Pregnancy specific risks and priorities

›Lower threshold for dehydration management with hyperemesis phenotype

›Broader differential including pregnancy related conditions

›Medication safety considerations

›Avoid tetracycline due to fetal effects

›Avoid bismuth subsalicylate due to salicylate exposure

›Metronidazole use only when benefits outweigh risks per local guidance

›H pylori strategy in pregnancy

›Defer eradication therapy until postpartum when possible

›Symptom control with pregnancy compatible acid suppression

Geriatric

›Higher risk phenotype

›NSAID associated ulcer risk amplified

›Higher likelihood of atypical presentation and silent bleeding

›Medication adjustments

›Renal function guided dosing for antibiotics

›Polypharmacy interaction screening with proton pump inhibitors and antiplatelets

›Disposition bias

›Lower threshold for admission with anemia or comorbidity

›Early endoscopy planning for suspected bleeding

Pediatrics

›Epidemiology and testing posture

›H pylori testing primarily when ulcer disease confirmed or strongly suspected

›Avoid test and treat strategy for nonspecific abdominal pain

›Weight based acid suppression

›Omeprazole 1 mg/kg/day divided once or twice daily maximum 40 mg/day

›Pantoprazole 1 mg/kg/day once daily maximum 40 mg/day

10Background/b30

Epidemiology

›Disease burden

›Peptic ulcer disease as a leading cause of nonvariceal upper GI bleeding

›Helicobacter pylori and NSAIDs as dominant etiologies

›Complication patterns

›Bleeding as most common acute complication

›Perforation associated with higher mortality

›Recurrence drivers

›Persistent H pylori infection

›Ongoing NSAID or aspirin exposure without gastroprotection

Pathophysiology

›Core mechanism

›Imbalance between mucosal defenses and acid pepsin injury

›Ulcer crater formation in gastric or duodenal mucosa

›Helicobacter pylori mediated injury

›Chronic active gastritis

›Increased acid output in antral predominant infection

›Impaired mucosal defenses and inflammation

›NSAID mediated injury

›COX inhibition with reduced prostaglandin synthesis

›Reduced mucus and bicarbonate production

›Microvascular injury and impaired healing

Therapeutic Considerations

›Proton pump inhibitor rationale

›Higher intragastric pH improves clot stability in bleeding ulcers

›Faster symptom relief and higher healing rates vs H2 blockers

›Eradication rationale

›H pylori eradication reduces ulcer recurrence and rebleeding

11Patient Discharge Instructions/pdi19

copy discharge instructions

›Medication and adherence

›Proton pump inhibitor exactly as prescribed

›Complete full antibiotic course if treated for H pylori

›Avoidance and lifestyle

›Avoid NSAIDs including ibuprofen and naproxen unless specifically advised

›Avoid tobacco

›Limit alcohol

›Follow up and testing

›Primary care or gastroenterology follow up within 2 to 4 weeks

›Test of cure for H pylori at least 4 weeks after antibiotics

›Hold proton pump inhibitor 14 days before test of cure when instructed

›Return to emergency department immediately for

›Vomiting blood

›Black tarry stools

›Fainting or near fainting

›Chest pain or trouble breathing

›Severe worsening abdominal pain

›Persistent vomiting or inability to keep fluids down

›Fever with severe abdominal pain

12References/r16

Clinical guidelines and consensus

›Upper GI bleeding and ulcer bleeding guidelines

›American College of Gastroenterology guideline on upper gastrointestinal and ulcer bleeding 2021

›European Society of Gastrointestinal Endoscopy guideline on nonvariceal upper GI hemorrhage update 2021

›Helicobacter pylori guidelines

›American College of Gastroenterology clinical guideline on treatment of Helicobacter pylori infection 2024

›Maastricht VI Florence consensus report on management of Helicobacter pylori

›Toronto consensus on management of Helicobacter pylori infection

Evidence based sources and tools

›Risk stratification and decision support

›Glasgow Blatchford Score derivation and validation studies

›ED risk stratification literature comparing Glasgow Blatchford Score and alternative scores

›Therapeutic evidence

›Randomized trials supporting restrictive transfusion thresholds in upper GI bleeding

›Meta analyses of high dose proton pump inhibitor strategies after endoscopic hemostasis

›Reference calculators

›Glasgow Blatchford Score calculator

›Rockall score references for post endoscopy risk assessment

Evidence & Review

Evidence & Review