INTRODUCTION
Patients with acute upper gastrointestinal (GI) bleeding commonly present with hematemesis (vomiting of blood or coffee-ground-like material) and/or melena (black, tarry stools). The initial evaluation of patients with acute upper GI bleeding involves an assessment of hemodynamic stability and resuscitation if necessary. Diagnostic studies (usually endoscopy) follow, with the goals of diagnosis, and when possible, treatment of the specific disorder.The diagnostic and initial therapeutic approach to patients with clinically significant (ie, the passage of more than a scant amount of blood) acute upper GI bleeding will be reviewed here. While there is variability among guidelines, this approach is generally consistent with a multidisciplinary international consensus statement updated in 2019, a 2012 guideline issued by the American Society for Gastrointestinal Endoscopy, a 2021 guideline issued by the American College of Gastroenterology, a 2015 guideline issued by the European Society of Gastrointestinal Endoscopy, and a 2021 update issued by the European Society of Gastrointestinal Endoscopy [1-5]. The causes of upper GI bleeding, the endoscopic management of acute upper GI bleeding, and the management of active variceal hemorrhage are discussed separately. (See "Causes of upper gastrointestinal bleeding in adults" and "Overview of the treatment of bleeding peptic ulcers" and "Overview of the management of patients with variceal bleeding" and "Methods to achieve hemostasis in patients with acute variceal hemorrhage".)
A table outlining the major causes, clinical features, and emergency management of acute severe upper gastrointestinal bleeding in adults is provided (table 1).
INITIAL EVALUATION
The initial evaluation of a patient with a suspected clinically significant acute upper GI bleed includes a history, physical examination, and laboratory tests. The goal of the evaluation is to assess the severity of the bleed, identify potential sources of the bleed, and determine if there are conditions present that may affect subsequent management. The information gathered as part of the initial evaluation is used to guide decisions regarding triage, resuscitation, empiric medical therapy, and diagnostic testing.Factors that are predictive of a bleed coming from an upper GI source identified in a meta-analysis included a patient-reported history of melena (likelihood ratio [LR] 5.1-5.9), melenic stool on examination (LR 25), blood or coffee grounds detected during nasogastric lavage (LR 9.6), and a ratio of blood urea nitrogen to serum creatinine greater than 30 (LR 7.5) [6]. On the other hand, the presence of blood clots in the stool made an upper GI source less likely (LR 0.05). Factors associated with severe bleeding included red blood detected during nasogastric lavage (LR 3.1), tachycardia (LR 4.9), or a hemoglobin level of less than 8 g/dL (LR 4.5-6.2).