Call Book

Bleeding proximal to Treitz

Hematemesis or melena; hematochezia if the bleed is torrential. Clots in the stool make UGIB less likely but do not exclude a brisk source (; ; ).

High-risk features: hypotension, tachycardia, INR >1.5, Hb <10, AMS, syncope, age >65, liver disease, heart failure.
Workup: CBC q2–8 h, CMP, coags, type and screen, orthostatics, abdominal exam, rectal exam (smear dark stool on a white napkin if the color is ambiguous).

GBS 0–1: very low risk of needing intervention — consider outpatient management (Lancet 2000;356:1318; Annals 2019;171:805; BMJ 2017;356:i6432; Gut 2021;70:707). ABC score estimates 30-day mortality. Rockall needs endoscopy.

Glasgow-Blatchford	Points
BUN 18.2–22.4 / 22.4–28 / 28–70 / ≥70 mg/dL	2 / 3 / 4 / 6
Hb men 12–13 or women 10–12	1
Hb men 10–12	3
Hb <10 (either sex)	6
SBP 100–109 / 90–99 / <90	1 / 2 / 3
HR ≥100	1
Melena	1
Syncope	2
Liver disease / heart failure	2 / 2

Stabilize, then intervene

NPO. Two large-bore IVs (≥18 G). Intubate for massive hematemesis or AMS — protect the airway before the scope.
Blood products over crystalloid for hypotension; crystalloid is fine while blood is coming. Do not delay transfusion in active hemorrhage.

EGD within 24 h. Timing 0–6 h vs 6–24 h does not change outcomes in non-variceal, hemodynamically stable bleeds (). Barium is contraindicated. NG lavage does not improve outcomes and is not required (ERGH 2017;12:63).
Call surgery / IR if unstable or endoscopy is not the right tool.

Pre-endoscopy drugs

Forrest classification — who rebleeds

Tools: epinephrine ± ethanol injection, bipolar / heater probe, clips, banding, balloon, TC-325 powder as rescue. Ia–IIb leave the room on high-dose PPI.

Class	What you see	Rebleed	Endoscopic therapy
Ia	Active arterial (spurting) bleeding	~85%	Yes — dual therapy + high-dose PPI
Ib	Oozing without a visible vessel	~30%	Yes
IIa	Non-bleeding visible vessel	~40%	Yes
IIb	Adherent clot	~25%	Yes (after clot removal in most protocols)
IIc	Flat pigmented spot	~10%	No — PPI, observe
III	Clean ulcer base	~3%	No

High-risk PUD post-EGD: pantoprazole 40 mg IV BID × 72 h (intermittent dosing non-inferior to bolus + drip; JAMA IM 2014;174:1755), then PO BID × 2–8 weeks. Treat H. pylori if positive.
Variceal: octreotide 2–5 d, ceftriaxone 5–7 d, restart beta-blocker day 5. Rebleed → repeat EGD, balloon tamponade as a , or TIPS. Early / preemptive TIPS (<72 h) in high-risk patients (: ).
Angiodysplasia: consider long-term octreotide () or bevacizumab with GI input.
Rebleed: repeat EGD vs CTA + IR / surgery.

Antithrombotics and sources

Warfarin: hold. Vitamin K ± PCC if reversal benefit outweighs thrombosis. Resume after hemostasis (UFH ~48 h if indicated). In AF, resuming within 7 days cuts thrombosis and death ().
DOAC: hold. Idarucizumab (dabigatran) or andexanet (factor Xa) first-line; PCC if specific reversal is unavailable. Resume within 72 h if high thrombotic risk, within 7 days if low (; ).
ASA: continue if low–moderate risk bleed; hold only if high-risk unless recent PCI / ACS. Resume secondary-prevention ASA once hemostasis is confirmed — 30-day mortality rises if you do not (). Add a PPI after PUD.
DAPT after PCI/ACS: talk to cardiology. <30 d post-PCI or <90 d post-ACS, continue both unless the bleed is life-threatening. Restarting sooner trades bleed for fewer vascular events ().

Dig Dis Sci 2018;63:1286.

Source	Share / notes
PUD (duodenal > gastric)	~50%. H. pylori, NSAID, alcohol, tobacco, Cameron lesion, ZES
Esophagitis / gastritis	~30%. GERD, pills (doxy, iron), ASA/NSAID, clopidogrel, alcohol, infection
Varices	~5%. Esophageal > gastric
Vascular	~5–10%. Dieulafoy, AVM, GAVE, HHT, radiation ectasia, aortoenteric fistula
Traumatic	~5%. Mallory-Weiss, foreign body, Boerhaave
Neoplastic / post-procedure / biliary	~5% / variable. Hemobilia, hemosuccus pancreaticus