Upper GI Bleed

Question 1

Bleeding originating from the esophagus, stomach, or duodenum (proximal to the ligament of Treitz)

Answer 1

Upper gastrointestinal bleeding

Question 2

This type of GI bleeding accounts for ~70–80% of all GI hemorrhages and is a common cause of ED visits and hospitalizations.

Answer 2

Upper gastrointestinal bleeding

Question 3

Two major etiologic classifications of acute upper GI bleeding

Answer 3

Non-variceal UGIB and variceal UGIB

Question 4

Most common type of upper GI bleeding; typically less severe and often due to peptic ulcer disease, erosive gastritis, or Mallory-Weiss tear.

Answer 4

Non-variceal upper GI bleeding

Question 5

Most severe form of upper GI bleeding; caused by rupture of portal-hypertension–related collateral vessels and associated with cirrhosis.

Answer 5

Variceal upper GI bleeding

Question 6

Pathogenesis - type of bleeding: Mucosal injury from gastric acid, NSAIDs, or H. pylori leading to erosion of submucosal vessels and bleeding

Answer 6

Non-variceal upper GI bleeding

Question 7

Pathogenesis - type of bleeding: Increased portal venous pressure → collateral vessel (varix) formation → rupture due to high pressure

Answer 7

Variceal upper GI bleeding

Question 8

Clinical - type of bleeding: UGIB that usually presents with melena or hematemesis and is often self-limited or controlled endoscopically

Answer 8

Non-variceal upper GI bleeding

Question 9

Clinical - type of bleeding: UGIB that presents with massive hematemesis, high risk of hypovolemic shock, and frequent recurrence without definitive therapy.

Answer 9

Variceal upper GI bleeding

Question 10

Management - type of bleeding: Endoscopic hemostasis + IV proton pump inhibitor + eradication of H. pylori + discontinuation of NSAIDs/anticoagulants

Answer 10

Management of non-variceal UGIB

Question 11

Management - type of bleeding: Hemodynamic stabilization + vasoactive drugs (e.g., octreotide/terlipressin) + endoscopic band ligation + antibiotic prophylaxis ± TIPS.

Answer 11

Management of variceal UGIB

Question 12

Peptic ulcer disease, esophagitis, and erosive gastritis belong to which etiologic category of UGIB?

Answer 12

Erosive / inflammatory causes

Question 13

Varices, angiodysplasia, Dieulafoy lesion, and gastric antral vascular ectasia belong to which etiologic category of UGIB?

Answer 13

Vascular causes

Question 14

Esophageal cancer and gastric cancer as sources of bleeding belong to which etiologic category of UGIB?

Answer 14

Tumor causes

Question 15

Mallory-Weiss tear, Boerhaave syndrome, foreign body ingestion, and post-procedural bleeding belong to which etiologic category of UGIB

Answer 15

Traumatic/Iatrogenic cause

Question 16

Chronic NSAID use, H. pylori infection, acid hypersecretion, tobacco/alcohol use, physiologic stress (critical illness, CNS injury, major burns),** are risk factors for which type of bleeding? **

Answer 16

Risk factors for non-variceal UGIB

Question 17

Cirrhosis, portal hypertension (>12 mmHg), portal vein thrombosis, hepatitis, hepatocellular carcinoma, alcohol use, are risk factors for which type of bleeding?

Answer 17

Risk factors for variceal UGIB

Question 18

This is the most common cause of acute upper gastrointestinal bleeding and results from an imbalance between protective mucosal defenses and injurious factors.
Endogenous factors include acid, pepsin, and bile, while exogenous factors include infection, drugs, and smoking, leading to mucosal inflammation, epithelial injury, and eventual vessel erosion with bleeding

Specific causes of acute upper GI bleeding

Answer 18

Peptic ulcer disease

Question 19

Use of these drugs inhibits COX (especially COX-1) → ↓ conversion of arachidonic acid to prostaglandins → ↓ mucus and bicarbonate secretion, ↓ epithelial restitution, ↑ apoptosis → mucosal injury and bleeding

Specific causes of acute upper GI bleeding

Answer 19

Peptic ulcer disease due to NSAIDs

Question 20

Massive arterial upper GI bleeding caused by a large, aberrant submucosal artery that erodes through normal mucosa without an associated ulcer, most commonly located along the proximal lesser curvature of the stomach near the gastroesophageal junction; often difficult to diagnose endoscopically.

Specific causes of acute upper GI bleeding

Answer 20

Dieulafoy lesion

Question 21

Upper GI bleeding due to portal hypertension (>12 mmHg) → formation of portosystemic collaterals → progressive vascular dilation and wall tension leading to rupture, typically presenting with severe hematemesis and high risk of hypovolemic shock

Specific causes of acute upper GI bleeding

Answer 21

Gastroesophageal varices

Question 22

Upper GI bleeding caused by a longitudinal mucosal laceration at the gastroesophageal junction following repeated vomiting, retching, or sudden increase in intra-abdominal pressure, exposing underlying vessels; bleeding is often self-limited and superficial

Specific causes of acute upper GI bleeding

Answer 22

Mallory-Weiss tear

Question 23

NSAIDs, alcohol, stress, acid, or infection disrupt the mucosal barrier → acute inflammation and surface erosions → diffuse oozing bleeding rather than a single visible vessel**

Specific causes of acute upper GI bleeding

Answer 23

Erosive gastropathy / gastritis / esophagitis

Question 24

Upper GI bleeding in GERD or immunocompromised patients caused by mucosal inflammation and friability, typically presenting as slow, diffuse bleeding

Specific causes of acute upper GI bleeding

Answer 24

Erosive esophagitis

Question 25

Bleeding due to tumor ulceration with neovascularization and mucosal invasion, often presenting with chronic blood loss, anemia, weight loss, and occult or persistent bleeding | Specific causes of acute upper GI bleeding

Answer 25

Upper GI malignancy

Question 26

**Linear erosions at the neck of a large hiatal hernia **caused by repetitive mechanical trauma and focal ischemia from diaphragmatic compression, presenting with chronic occult bleeding and iron-deficiency anemia and often difficult to detect on endoscopy**** | Specific causes of acute upper GI bleeding

Answer 26

Cameron lesion

Question 27

Chronic upper GI bleeding **due to gastric antral vascular ectasia** with dilated mucosal vessels and **fibromuscular hyperplasia**, classically showing **longitudinal red stripes radiating from the pylorus** (“watermelon stomach”) and associated with cirrhosis, portal hypertension, or systemic sclerosis | Specific causes of acute upper GI bleeding

Answer 27

Watermelon Stomach - Gastric antral vascular ectasia (GAVE)

Question 28

Immediate priority in suspected upper GI bleeding is rapid resuscitation with the goal of restoring hemodynamic stability

Answer 28

Initial management of upper GI bleeding

Question 29

Components of the initial evaluation of UGIB

Answer 29

Initial assessment in upper GI bleeding includes vital signs, evaluation for shock or hypovolemia, and review of major comorbidities such as malignancy, CAD, or COPD

Question 30

The clinical characteristics of bleeding that are most typical for upper GI bleeding are __________and ________

Answer 30

Hematemesis and melena **⭐ Hematochezia occurs in ~10% when bleeding is brisk**

Question 32

Vomiting blood that may be bright red or brown and can resemble coffee grounds depending on the rate and duration of bleeding

Answer 32

Hematemesis

Question 33

Vomitus containing dark granular material representing old, partially digested blood exposed to gastric acid

Answer 33

Coffee-ground emesis

Question 34

Black, tarry, foul-smelling stool caused by digestion of blood as it passes through the GI tract

Answer 34

Melena

Question 35

Passage of fresh blood per rectum, usually from lower GI bleeding but seen in ~10% of brisk upper GI bleeds

Answer 35

Hematochezia

Question 36

Clinical findings suggesting acute severe blood loss or hypovolemia, including tachycardia, hypotension, altered mental status, syncope, and orthostatic hypotension, along with signs of anemia such as pallor and fatigue and clues to the underlying cause (e.g., cirrhosis, weight loss, abdominal pain, nausea/vomiting

Answer 36

Systemic clinical manifestations of significant UGIB

Question 37

A risk stratification tool for upper GI bleeding that uses only clinical and laboratory data available at initial presentation, does not require endoscopy, and is used to identify low-risk patients suitable for outpatient management and high-risk patients who need transfusion or urgent endoscopic intervention

Answer 37

Glasgow–Blatchford score

Question 38

This upper GI bleeding score includes hemoglobin, blood urea nitrogen, pulse rate, systolic blood pressure, presence of syncope, melena, liver disease, and heart failure, and a value ≤1 allows safe discharge with early outpatient endoscopy

Answer 38

Glasgow–Blatchford score

Question 39

A high-risk stratification score for upper GI bleeding that uses only data available at initial presentation, is highly predictive of mortality (may outperform GBS for this purpose), and includes albumin <3 g/dL, INR >1.5, altered mental status, systolic BP <90 mmHg, and age ≥65, with ≥2 factors indicating high risk

Answer 39

AIMS65 score

Question 40

An endoscopic classification applied after visualization of a bleeding lesion that predicts risk of rebleeding and guides the need for endoscopic therapy, where active bleeding or high-risk stigmata require intervention and low-risk stigmata are managed conservatively

Answer 40

Forrest classification

Question 41

Endoscopic classification in which: Stage I = active hemorrhage, Stage II = recent/inactive hemorrhage, Stage III = lesion without active bleeding (clean base)

Answer 41

Forrest classification stages ## Footnote ⭐ Endoscopic therapy is indicated for Ia, Ib, and IIa

Question 42

The first step in the diagnostic approach to suspected GI bleeding is to assess whether the patient is

Answer 42

hemodynamically stable or unstable

Question 43

If the patient is hemodynamically unstable, the initial study and gold standard is ______, if this is not possible or nondiagnostic → consider ______________________.

Answer 43

EGD (upper endoscopy) → mesenteric angiography

Question 44

If the patient is hemodynamically stable, the initial study and gold standard is ______________________; if nondiagnostic → consider ______________________ or ______________________; if the workup remains negative → evaluate for ______________________ with push/deep enteroscopy. → EGD → colonoscopy (in melena) or CT angiography → small-bowel bleeding

Answer 44

EGD → colonoscopy (in melena) or CT angiography → small-bowel bleeding

Question 45

The ______________________ allows direct visualization of the GI tract, bleeding source identification, diagnostic biopsies, and endoscopic hemostasis, and is the gold standard for upper (and lower) GI bleeding

Answer 45

Endoscopy (EGD/colonoscopy)

Question 46

The ______________________ is an imaging procedure that uses X-rays and contrast dye to visualize mesenteric arteries and veins, and is used when endoscopy is contraindicated, nondiagnostic, or in suspected active bleeding—especially in hemodynamically unstable patients.

Answer 46

Mesenteric angiography

Question 47

A ______________________ is a non-invasive modality of mesenteric angiography that uses CT technology with IV iodinated contrast to visualize vessels and rapidly localize the bleeding source to guide hemostatic intervention

Answer 47

CT angiography

Question 48

______________________ is a catheter-based modality of mesenteric angiography that is both diagnostic and therapeutic when combined with angioembolization

Answer 48

Catheter angiography

Question 49

What is the initial approach for the management of upper GI bleeding? Obtain ______________________ for possible fluid resuscitation and blood transfusion (→ place two large-bore peripheral IV lines), keep the patient ______________________, begin management based on ______________________, and consider empiric pharmacologic therapy

Answer 49

intravenous access / NPO status / hemodynamic stability

Question 50

In the management of ______________________, follow the ABCDE approach (airway, breathing, circulation, disability, exposure), consider intubation for airway protection, start immediate IV crystalloid resuscitation, give blood transfusion, and consider anticoagulation reversal

Answer 50

hemodynamically unstable patients

Question 51

In ______________________, follow a restrictive transfusion strategy with packed RBC transfusion when hemoglobin <7 g/dL (or <8 g/dL in cardiovascular disease or delayed endoscopy)

Answer 51

hemodynamically stable patients

Question 52

Prior to EGD, recommended medications include ______________________ to promote gastric emptying and improve visualization, ______________________, and if variceal bleeding is suspected → ______________________ plus ______________________

Answer 52

erythromycin / pre-procedural PPIs / vasoactive therapy (e.g., octreotide) / antibiotic prophylaxis

Question 53

The function of proton pump inhibitors in upper GI bleeding is to maintain gastric pH >6 and prevent ______________________ of ulcer clots.

Answer 53

fibrinolysis

Question 54

The role of octreotide in upper GI bleeding is first-line therapy for variceal bleeding and an ______________________ in selected non-variceal cases, especially with ______________________ despite optimal PPI therapy

Answer 54

adjunctive treatment / persistent bleeding

Question 55

______________________ is the preferred intervention for patients with ongoing bleeding or signs of recent bleeding on endoscopy

Answer 55

Endoscopic therapy

Question 56

The recommended timing for upper endoscopy in upper GI bleeding is within ______________________ of presentation

Answer 56

24 hours

Question 57

Endoscopic methods to control bleeding include ______________________, ______________________, ______________________, and mechanical therapies such as ______________________ and ______________________.

Answer 57

injection therapy / contact thermal therapy / non-contact thermal therapy / hemostatic clips / band ligation

Question 58

Combination endoscopic therapy typically consists of ______________________ plus ______________________ or ______________________ methods.

Answer 58

injection therapy / thermal / mechanical

Question 59

______________________ is indicated for identification of an arterial source of UGIB on endoscopy and in patients with rebleeding or ongoing bleeding despite endoscopic hemostasis. Its main techniques include angioembolization (preferred) and intra-arterial vasopressin infusion for diffuse bleeding.

Answer 59

Interventional radiology (catheter angiography)

Question 60

______________________ is considered in patients with ongoing GI bleeding only when all other therapeutic options have failed or in refractory hemodynamic instability, and includes surgical ligation of bleeding vessels, excision of susceptible mucosa (e.g., Dieulafoy lesion), or segmental bowel resection.

Answer 60

Surgical hemostasis

Question 61

All patients with acute non-variceal upper GI bleeding should be tested for ______________________ infection; patients who test positive must receive ______________________, and eradication must be confirmed with follow-up testing at least ______________________ after completion of therapy

Answer 61

H. pylori / antibiotics / 4 weeks

Question 62

Major complications of upper GI bleeding include ______________________, ______________________ (especially in cirrhotic patients), and ______________________.

Answer 62

hemorrhagic shock / hepatic encephalopathy / aspiration pneumonia

Question 63

Study the management algorithm for UGIB!!

Answer 63

Good!