Practical Approach to Acute Gastrointestinal Bleeding Christopher S. Huang MD Assistant Professor of...

Practical Approach to Acute Gastrointestinal Bleeding

Christopher S. Huang MDAssistant Professor of Medicine

Boston University School of MedicineSection of Gastroenterology

Boston Medical Center

Learning Objectives

• UGIB– Nonvariceal (PUD) and variceal– Resuscitation, risk assessment, pre-endoscopy

management– Role of endoscopy– Post-endoscopy management

• LGIB– Risk assessment– Role and timing of colonoscopy– Non-endoscopic diagnostic and treatment options

Definitions

• Upper GI bleed – arising from the esophagus, stomach, or proximal duodenum

• Mid-intestinal bleed – arising from distal duodenum to ileocecal valve

• Lower intestinal bleed – arising from colon/rectum

Stool color and origin/pace of bleeding

• Guaiac positive stool– Occult blood in stool – Does not provide any localizing information– Indicates slow pace, usually low volume bleeding

• Melena– Very dark, tarry, pungent stool– Usually suggestive of UGI origin (but can be small

intestinal, proximal colon origin if slow pace)• Hematochezia

– Spectrum: bright red blood, dark red, maroon – Usually suggestive of colonic origin (but can be UGI origin

if brisk pace/large volume)

Case Vignette – CC:

• 68 yo male presents with a chief complaint of a large amount of “bleeding from the rectum”

Case Vignette - HPI

• Describes bleeding as large volume, very dark maroon colored stool

• Has occurred 4 times over past 3 hours• He felt light headed and nearly passed out

upon trying to get up to go the bathroom

Case Vignette - HPI

• Denies abdominal pain, nausea, vomiting, antecedent retching

• No history of heartburn, dysphagia, weight loss

• No history of diarrhea or constipation/hard stools

• No prior history of GIB• Screening colonoscopy 10 years ago – no

polyps, (+) diverticulosis

Case Vignette – PMHx, Meds

• Hepatitis C• CAD – h/o MI• PVD• AAA – s/p elective

repair 3 years ago• HTN• Hypercholesterolemia• Lumbago

• Medications:– Aspirin– Clopidogrel– Atorvastatin– Atenolol– Lisinopril

Case Vignette – Physical Exam

• Physical examination:– BP 105/70, Pulse 100, (+) orthostatic changes– Alert and mentating, but anxious appearing– Anicteric– Mid line scar, benign abdomen, nontender liver

edge palpable in epigastrium, no splenomegaly– Rectal examination – no masses, dark maroon

blood

Case Vignette - Labs

• Labs– Hct 21% (Baseline 33%)– Plt 110K– BUN 34, Cr 1.0– Alb 3.5– INR 1.6– ALT 51, AST 76

Initial Considerations

• Differential diagnosis?– What is most likely source? – What diagnosis can you least afford to miss?

• How sick is this patient? (risk stratification)– Determines disposition– Guides resuscitation– Guides decision re: need for/timing of endoscopy

Differential Diagnosis – Upper GIB

• Peptic ulcer disease• Gastroesophageal varices• Erosive esophagitis/gastritis/duodenitis• Mallory Weiss tear• Vascular ectasia• Neoplasm• Dieulafoy’s lesion• Aortoenteric fistula• Hemobilia, hemosuccus pancreaticus

Rare, but cannot afford to miss

Rare, but cannot afford to miss

Most common

Most common

Differential Diagnosis – Lower GIB

• Diverticulosis • Angioectasias• Hemorrhoids• Colitis (IBD, Infectious, Ischemic)• Neoplasm• Post-polypectomy bleed (up to 2 weeks after

procedure)• Dieulafoy’s lesion

Most common diagnosis

Most common diagnosis

History and Physical

History• Localizing symptoms• History of prior GIB• NSAID/aspirin use• Liver disease/cirrhosis• Vascular disease• Aortic valvular disease,

chronic renal failure• AAA repair• Radiation exposure• Family history of GIB

Physical Examination• Vital signs, orthostatics• Abdominal tenderness• Skin, oral examination• Stigmata of liver disease• Rectal examination

– Objective description of stool/blood

– Assess for mass, hemorrhoids– No need for guaiac test

History and Physical

History• Localizing symptoms• History of prior GIB• NSAID/aspirin use• Liver disease/cirrhosis• Vascular disease• Aortic valvular disease,

chronic renal failure• AAA repair• Radiation exposure• Family history of GIB

Physical Examination• Vital signs, orthostatics• Abdominal tenderness• Skin, oral examination • Stigmata of liver disease• Rectal examination

– Objective description of stool/blood

– Assess for mass, hemorrhoids– No need for guaiac test

Always get objective description of stool

Always get objective description of stool

Take Home Point # 1

Avoid noninformative terms such as “grossly guaiac positive”

Avoid noninformative terms such as “grossly guaiac positive”

If you need a card to tell you whether there’s blood in the stool, it’s NOT an

acute GIB

If you need a card to tell you whether there’s blood in the stool, it’s NOT an

acute GIB

Take Home Point #2

Narrowing the DDx: Upper or Lower Source?

• Predictors of UGI source:– Age <50– Melenic stool – BUN/Creatinine ratio

• If ratio ≥ 30, think upper GIB

J Clin Gastroenterol 1990;12:500Am J Gastroenterol 1997;92:1796Am J Emerg Med 2006;24:280

• Most useful situation: patients with severe hematochezia, and unsure if UGIB vs. LGIB– Positive aspirate (blood/coffee grounds) indicates

UGIB• Can provide prognostic info:

– Red blood per NGT – predictive of high risk endoscopic lesion

– Coffee grounds – less severe/inactive bleeding• Negative aspirate – not as helpful; 15-20% of

patients with UGIB have negative NG aspirateAnn Emerg Med 2004;43:525Arch Intern Med 1990;150:1381Gastrointest Endosc 2004;59:172

Utility of NG Tube

Take Home Point #3

Upper GI bleed must still be considered in patients with severe hematochezia, even if NG aspirate

negative

Upper GI bleed must still be considered in patients with severe hematochezia, even if NG aspirate

negative

Initial Assessment

• Always remember to assess A,B,C’s• Assess degree of hypovolemic shock

Resuscitation

• IV access: large bore peripheral IVs best (alt: cordis catheter)

• Use crystalloids first• Anticipate need for blood transfusion

• Threshold should be based on underlying condition, hemodynamic status, markers of tissue hypoxia

• Should be administered if Hgb ≤ 7 g/dL• 1 U PRBC should raise Hgb by 1 (HCT by 3%)• Remember that initial Hct can be misleading (Hct remains

the same with loss of whole blood, until re-equilibration occurs)

• Correct coagulopathy

Resuscitation







40%40%40%40% 20%20%

bleed Time

IVFs

Transfusion Strategy

• Randomized trial: – 921 subjects with severe acute UGIB– Restrictive (tx when Hgb<7; target 7-9) vs. Liberal

(tx when Hgb<9; target 9-11)– Primary outcome: all cause mortality rate within

45 days

NEJM 2013;368;11-21

Restrictive Strategy Superior

Restrictive Liberal P value

Mortality rate 5% 9% 0.02

Rate of further bleeding

10% 16% 0.01

Overall complication rate

40% 48% 0.02

NEJM 2013;368;11-21

Benefit seen primarily in Child A/B cirrhotics

Resuscitation







Weigh risks and benefits of reversing anticoagulation

Assess degree of coagulopathy

Vitamin K – slow acting, long-lived

FFP – fast acting, short lived- Give 1 U FFP for every 4 U PRBCs

Weigh risks and benefits of reversing anticoagulation

Assess degree of coagulopathy

Vitamin K – slow acting, long-lived

FFP – fast acting, short lived- Give 1 U FFP for every 4 U PRBCs

Resuscitation

• Early intensive resuscitation reduces mortality– Consecutive series of patients with

hemodynamically significant UGIB– First 36 subjects = Observation Group (no

intervention)– Second 36 subjects = Intensive Resuscitation

Group (intense guidance provided) – goal was to decrease time to correction of hemodynamics, Hct and coagulopathy

Am J Gastroenterol 2004;99:619

Early Intensive Resuscitation Reduces UGIB Mortality

Am J Gastroenterol 2004;99:619(groups are essentially the same)

Intervention: Faster correction of hemodynamics, Hct and coags.

Time to endoscopy similar

• Observation group– 5 MI– 4 deaths

• Intense group– 2 MI– 1 death (sepsis)

Early Intensive Resuscitation Reduces UGIB Mortality


Causes of Mortality in Patients with Peptic Ulcer Bleeding

• Patients rarely bleed to death

• Prospective cohort study >10,000 cases of peptic ulcer bleed

• Mortality rate 6.2%

• 80% of deaths not related to bleeding


Causes of Mortality in Patients with Peptic Ulcer Bleeding

• Most common causes of non-bleeding mortality:– Terminal malignancy (34%)– Multiorgan failure (24%)– Pulmonary disease (24%)– Cardiac disease (14%)


Take Home Point #4

Early resuscitation and supportive measures are critical to reduce

mortality from UGIB

Early resuscitation and supportive measures are critical to reduce

mortality from UGIB

• Identify patients at high risk for adverse outcomes

• Helps determine disposition (ICU vs. floor vs. outpatient)

• May help guide appropriate timing of endoscopy

Risk Stratification

Rockall Scoring System

• Validated predictor of mortality in patients with UGIB

• 2 components: clinical + endoscopicVariable 0 1 2 3

Age <60 60-79 ≥ 80

Shock NoSBP ≥ 100P<100

Tachy-SBP ≥ 100P>100

Hypotension-SBP <100

Comorbidity No major Cardiac failure, CAD, other major

Renal failure, liver failure, malignancy

Gut 1996;38:316

Clinical Rockall Score – Mortality Rates

AIMS65

• Simple risk score that predicts in-hospital mortality, LOS, cost in patients with acute UGIB

Gastrointest Endosc 2011;74:1215

AIMS65


Blatchford Score

• Predicts need for endoscopic therapy

• Based on readily available clinical and lab data

• Can use UpToDate calculator

Lancet 2000;356:1318

Blatchford Score


Blatchford Score

• Most useful for safely discriminating low risk UGIB patients who will likely NOT require endoscopic hemostasis

• “Fast track Blatchford” – patient at low risk if:

BUN < 18 mg/dLHgb > 13 (men), 12 (women)SBP >100HR < 100

• For Non-Variceal UGIB– IV PPI: 80 mg bolus, 8 mg/hr drip– Rationale: suppress acid, facilitate clot formation

and stabilization– Duration: at least until EGD, then based on

findings

Pre-endoscopic Pharmacotherapy

Pre-endoscopy PPI

• Reduces the proportion of patients with high risk endoscopic stigmata (“downstages” lesion)

• Decreases need for endoscopic therapy

• Has not been shown to reduce rebleeding, surgery, or mortality rates

N Engl J Med 2007;356:1631

Endoscopic treatment required:Omeprazole – 19% (23% of PUD)Placebo – 28% (37% of PUD)

High riskHigh risk Low riskLow risk

• Early endoscopy (within 24 hours) is recommended for most patients with acute UGIB

• Achieves prompt diagnosis, provides risk stratification and hemostasis therapy in high-risk patients

J Clin Gastroenterol 1996;22:267Gastrointest Endosc 1999;49:145Ann Intern Med 2010;152:101

Endoscopy - Nonvariceal UGIB

When is Endoscopic Therapy Required?

• ~80% bleeds spontaneously resolve• Endoscopic stigmata of recent hemorrhage

Stigmata Continued/rebleeding rate

Active bleeding 55-90%

Nonbleeding visible vessel 40-50%

Adherent clot Variable, depending on underlying lesion: 0-35%

Flat pigmented spot 7-10%

Clean base < 5%

major

Major Stigmata – Active Spurting

Kelsey, PB (Dec 04 2003). Duodenum - Ulcer, Arterial Spurting, Treated with Injection and Clip. The DAVE Project. Retrieved Aug, 1, 2010, from http://daveproject.org/viewfilms.cfm?film_id=39

Major Stigmata - NBVV

Adherent Clot

• Role of endoscopic therapy of ulcers with adherent clot is controversial

• Clot removal usually attempted

• Underlying lesion can then be assessed, treated if necessary

Minor Stigmata

Flat pigmented spot Clean base

Low rebleeding risk – no endoscopic therapy needed

Low rebleeding risk – no endoscopic therapy needed

Endoscopic Hemostasis Therapy

• Epinephrine injection• Thermal electrocoagulation• Mechanical (hemoclips)

• Combination therapy superior to monotherapy

Kelsey, PB (Nov 08 2005). Stomach - Gastric Ulcer, Visible Vessel. The DAVE Project. Retrieved Aug, 1, 2010, from http://daveproject.org/viewfilms.cfm?film_id=306

Baron, TH (May 01 2007). Duodenum - Bleeding Ulcer Treated with Thermal Therapy, Perforation Closed with Hemoclips. The DAVE Project. Retrieved Aug, 1, 2010, from http://daveproject.org/viewfilms.cfm?film_id=620

Nonvariceal UGIB –Post-endoscopy management

• Patients with low risk ulcers can be fed promptly, put on oral PPI therapy.

• Patients with ulcers requiring endoscopic therapy should receive PPI gtt x 72 hours– Significantly reduces 30 day rebleeding rate vs

placebo (6.7% vs. 22.5%)– Note: there may not be major advantage with

high dose over non-high dose PPI therapy

N Engl J Med 2000;343:310Arch Intern Med 2010;170:751

• Determine H. pylori status in all ulcer patients• Discharge patients on PPI (once to twice daily),

duration dictated by underlying etiology and need for NSAIDs/aspirin

• In patients with cardiovascular disease on low dose aspirin: restart as soon as bleeding has resolved– RCT demonstrates increased risk of rebleeding (10% v

5%) but decreased 30 day mortality (1.3% v 13%)


Ann Intern Med 2010;152:1

• Determine H. pylori status in all ulcer patients• Discharge patients on PPI (once to twice daily),

duration dictated by underlying etiology and need for NSAIDs/aspirin

• In patients with cardiovascular disease on low dose aspirin: restart as soon as bleeding has resolved– RCT demonstrates increased risk of rebleeding (10% v

5%) but decreased 30 day mortality (1.3% v 13%)


Ann Intern Med 2010;152:1

Not dying is more important than not rebleeding

Not dying is more important than not rebleeding

Variceal Bleeding

• Occurs in 1/3 of patients with cirrhosis• 1/3 initial bleeding episodes are fatal• Among survivors, 1/3 will rebleed within 6

weeks• Only 1/3 will survive 1 year or more

Predictors of large esophageal varices

• Severity of liver disease (Child Pugh)• Platelet count < 88K• Palpable spleen• Platelet count/spleen diameter (mm) ratio

<909

Gut 2003;52:1200J Clin Gastroenterol 2010;44:146J Gastroenterol Hepatol 2007;22:1909Arch Intern Med 2001;161:2564Am J Gastroenterol 1999;94:3103

• Goal: Reduce splanchnic blood flow• Terlipressin – only agent shown to improve control of

bleeding and survival in RCTs and meta-analysis– Not available in US

• Vasopressin + nitroglycerine – too many adverse effects

• Somatostatin – not available in US• Octreotide (somatostatin analogue)

• Decreases splanchnic blood flow (variably)• Efficacy is controversial; no proven mortality benefit• Standard dose: 50 mcg bolus, then 50 mcg/hr drip for 3-5 days

Gastroenterology 2001;120:946Cochrane Database Syst Rev 2008;16:CD000193N Engl J Med 1995;333:555Am J Gastroenterol 2009;104:617

• Bacterial infection occurs in up to 66% of patients with cirrhosis and variceal bleed

• Negative impact on hemostasis (endogenous heparinoids)

• Prophylactic antibiotics reduces incidence of bacterial infection, significantly reduces early rebleeding– Ceftriaxone 1 g IV QD x 5-7 days– Alt: Norfloxacin 400 mg po BID

Hepatology 2004;39:746J Korean Med Sci 2006;21:883Hepatogastroenterology 2004;51:541

• Promptly but with caution• Goal = maintain hemodynamic stability, Hgb

~7-8, CVP 4-8 mmHg• Avoid excessively rapid overexpansion of

volume; may increase portal pressure, greater bleeding

• Should be performed as soon as possible after resuscitation (within 12 hours)

• Endotracheal intubation frequently needed

• Band ligation is preferred method

Layer, L. & Jaganmohan, S. & Raju, GS & DuPont, AW (Oct 28 2009). Esophagus - Band Ligation of Actively Bleeding Gastroesophageal Varices. The DAVE Project. Retrieved Aug, 2, 2010, from http://daveproject.org/viewfilms.cfm?film_id=715

• TIPS – Transjugular Intrahepatic Portosystemic Shunt

• Early placement of shunt (within 24-72hrs) associated with improved survival among high-risk patients

• Preferred treatment for gastric variceal bleeding (rule out splenic vein thrombosis first)

Fan, C. (Apr 25 2006). Vascular Interventions in the Abdomen: New Devices and Applications. The DAVE Project. Retrieved Aug, 2, 2010, from http://daveproject.org/viewfilms.cfm?film_id=497Hepatology 2004;40:793

Hepatology 2008;48:Suppl:373AN Engl J Med. 2010 Jun 24;362:2370

TIPS+embolization of gastric varices

Sengstaken-Blakemore Tube • Very effective for immediate, temporary control

• High complication rate – aspiration, migration, necrosis + perforation of esophagus

• Use as bridge to TIPS within 24 hours

• Airway protection strongly recommended

• Specially designed covered metal stent

• Tamponades distal esophageal varices

• Removable; does not require airway protection

• Very limited data

Self-Expanding Metal Stent


• Reduces risk for recurrent variceal hemorrhage

• Use nonselective beta blocker (e.g. Nadolol – splanchnic vasoconstriction, decrease cardiac output) and titrate up to maximum tolerated dose, HR 50-60– Start as inpatient, once acute bleeding has

resolved and patient shows hemodynamic stability

Lower GI Bleed

• Bleeding arising from the colorectum• In patients with severe hematochezia, first

consider possibility of UGIB– 10-15% of patients with presumed LGIB are found

to have upper GIB

Lower GI Bleed

• Differential Diagnosis

- Diverticulosis (# 1 cause)- Angioectasias- Hemorrhoids- Colitis (IBD, Infectious, Ischemic)- Neoplasm- Post-polypectomy- Dieulafoy’s lesion

- Diverticulosis (# 1 cause)- Angioectasias- Hemorrhoids- Colitis (IBD, Infectious, Ischemic)- Neoplasm- Post-polypectomy- Dieulafoy’s lesion

Large volume, painlessLarge volume, painless

Smaller volume, pain, diarrhea

Smaller volume, pain, diarrhea

LGIB – Risk Stratification

• Predictors of severe* LGIB:

HR>100 SBP<115 Syncope nontender abdominal examination bleeding during first 4 hours of evaluation aspirin use >2 active comorbid conditions

HR>100 SBP<115 Syncope nontender abdominal examination bleeding during first 4 hours of evaluation aspirin use >2 active comorbid conditions

0 factors: ~6% risk

1-3 factors: ~40%

>3 factors: ~80%

0 factors: ~6% risk

1-3 factors: ~40%

>3 factors: ~80%

Arch Intern Med 2003;163:838Am J Gastroenterol 2005;100:1821

* Defined as continued bleeding within first 24 hours (transfusion of 2+ Units, decline in HCT of 20+%) and/or recurrent bleeding after 24 hours of stability

LGIB – Risk Factors for Mortality

• Age• Intestinal ischemia• Comorbid illnesses

• Secondary bleeding (developed during admission for a separate problem)

• Coagulopathy• Hypovolemia• Transfusion requirement• Male gender

Clinical Gastro Hepatol 2008;6:1004

Role of Colonoscopy

• Like UGIB, ~80% of LGIBs will resolve spontaneously; of these, ~30% will rebleed

• Lack of standardized approach– Traditional approach:

• elective colonoscopy after resolution of bleeding, bowel prep – low therapeutic benefit

• Angiography for massive bleeding, hemodynamically unstable patient

– Urgent colonoscopy approach• Similar to UGIB – identify stigmata of hemorrhage, perform

therapy

Urgent Colonoscopy

• Within 6-12 hours of presentation• Requires rapid “purge” prep with 5-6 L

Golytely administered 1L every 30-45 minutes• Colonoscopy performed within 1 hour after

clearance of stool, blood and clots• Need for bowel prep and risks of procedural

sedation may be prohibitive in unstable patient

Endoscopic Therapy

Srinivasan, R. & Luthra, G. & Raju, GS (Jul 17 2007). Colon - Endoscopic Hemostasis of Diverticular Bleed. The DAVE Project. Retrieved Aug, 3, 2010, from http://daveproject.org/viewfilms.cfm?film_id=63

Urgent Colonoscopy

• Limited high quality evidence of benefit• Establishes diagnosis earlier, shorter length of

stay• “Landmark” study supporting urgent colonoscopy

for diverticular bleed published in 2000– 2 consecutive prospective, non-randomized studies– Group 1 (n=73): urgent colonoscopy, surgical therapy– Group 2 (n=48): urgent colonoscopy, endoscopic

therapy

N Engl J Med 2000;342:78

Urgent Colonoscopy

• Group 1: 17 pts with definite diverticular bleed – 9 had recurrent/persistent

bleeding– 6 required emergency

surgery• Group 2: 10 pts with

definite diverticular bleed– All 10 patients treated

endoscopically– 0 had recurrent bleed,

complications, further transfusions, or surgery

N Engl J Med 2000;342:78

Urgent Colonoscopy

• Two RCTs published to date

• Compared urgent colonoscopy (within 8 hours) vs. standard management


Standard Management Algorithm

Urgent Colonoscopy – RCT#1


Definite bleeding source identified more frequently (42% vs 22%)

Definite bleeding source identified more frequently (42% vs 22%)

But no significant difference in important outcomes (but underpowered)

But no significant difference in important outcomes (but underpowered)


• 85 patients with serious hematochezia (hemodynamically significant, Hgb drop > 1.5 g/dL, blood transfusion)

• EGD performed within 6 hours• If EGD negative, randomized to urgent (<12

hr) or elective (36-60 hr) colonoscopy• Primary endpoint= further bleeding


• EGD positive in 15%

• No evidence of improved clinical outcomes with urgent colonoscopy – but prespecified sample size not reached



Urgent Colonoscopy

• In published series, endoscopic therapy is applied in 10-40% of patients undergoing colonoscopy for LGIB

• Taken together, evidence suggests that colonoscopy should be performed within 12-24 hours in stable patients

• However, it is unclear how faster timing affects major clinical outcomes

Radiographic Studies

Tagged RBC scan• Noninvasive, highly

sensitive (0.05-0.1 ml/min)• Ability to localize bleeding

source correctly only ~66%• More accurate when

positive within 2 hours (95-100%)

• Lacks therapeutic capabilityCoordinate with IR so that positive scan is

followed closely by angiographyCoordinate with IR so that positive scan is

followed closely by angiography


Angiography• Detects bleeding rates of

0.5-1 ml/min• Therapeutic capability –

embolization with microcoils, polyvinyl alcohol, gelfoam

• Complications: bowel infarction, renal failure, hematomas, thromboses, dissection

Recommended test for patients with brisk bleeding who cannot be stabilized or

prepped for colonoscopy(or have had colonoscopy with failure to

localize/treat bleeding site)

Recommended test for patients with brisk bleeding who cannot be stabilized or

prepped for colonoscopy(or have had colonoscopy with failure to

localize/treat bleeding site)


Multi-Detector CT (CT angio)• Readily available, can be performed in

ER within 10 minutes• Can detect bleeding rate of 0.5 ml/min• Can localize site of bleeding (must be

active) and provide info on etiology• Useful in the actively bleeding but

hemodynamically stable patient


Role of Surgery

• Reserved for patients with life-threatening bleed who have failed other options

• General indications: hypotension/shock despite resuscitation, >6 U PRBCs transfused

• Preoperative localization of bleeding source important

Algorithmic Evaluation of Patient with Hematochezia

HematocheziaHematochezia

Assess activity of bleed

Assess activity of bleed

NG lavageNG lavage Prep for Colonoscopy

Prep for Colonoscopy

PositivePositive

EGDEGD

NegativeNegative

active inactive

Risk for UGIB

Hemodynamically stable?


No risk for UGIB

negativeTreat lesionTreat lesion positive

Algorithmic Evaluation of Patient with Hematochezia

Active Lower GIBActive Lower GIB



Angiography (+/- Tagged RBC

scan)Or

Surgery if life-threatening

Angiography (+/- Tagged RBC

scan)Or

Surgery if life-threatening

Consider “urgent colonoscopy” vs.

traditional approach

Consider “urgent colonoscopy” vs.

traditional approach

YesNo

Take Home Points

• Always get objective description of stool color (best way – examine it yourself)

• Don’t order guaiac tests on inpatients

• Severe hematochezia can be from UGIB, even if NG lavage is negative

Take Home Points

• All bleeding eventually stops (and majority of nonvariceal bleeds will stop spontaneously, with the patient alive)

• Early resuscitation and supportive care are key to reducing morbidity and mortality from GIB

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