Snapshot A 65-year-old man with a history of alcoholism, tobacco use, and hypertension presents to the emergency room with one episode of bloody emesis that occurred along with abdominal pain. He states that recently his stools have been black. Examination reveals spider angiomas but no palmar erythema or hepatosplenomegaly. An upper endoscopy was performed (See image on the right). Introduction Clinical definition a bleed from a source proximal to the ligament of Treitz Epidemiology incidence 1 out of 1,000 people will experience an upper GI bleed upper GI bleeds are 4x more common than lower GI bleeds risk factors alcohol consumption cigarette smoking liver disease NSAID use vomiting anticoagulation Etiology peptic ulcer disease gastritis esophageal varices in the setting of liver disease Mallory-Weis tear Boerhaave syndrome gastric cancer vascular abnormalities esophagitis Prognosis mortality rate 6-10% overall Presentation Symptoms hematemesis (coffee ground) hematochezia hypotension melanotic stools Physical exam abdominal pain anorexia bloody emesis Imaging Upper and lower endoscopy is the definitive study to confirm the diagnosis Angiography can be used to localize the source of a bleed and potentially intervene Studies Labs including CBC, BMP, PT/INR/PTT, and liver studies may have normal hematocrit not accurate measure of blood loss Nasogastric tube will decompress the stomach and help assess the color of the output Rectal exam and fecal occult test to assess for lower GI bleeding May need to intubate patient to maintain airway depending on severity of the bleed Treatment Medical IV fluid resuscitation and transfusions for hemodynamic stability underlying medical illness must be identified and treated antacid medications such as anti-histamines and proton pump inhibitors should be started H. pylori testing should occur in the setting of gastric ulcer and treatment should be initiated Surgical endoscopy with banding or sclerotherapy biopsy of the area of interest should be performed to rule out bleeding malignancy interventional radiology for possible identification and embolization of bleeding vessel surgical exploration may be required if uncontrollable bleeding, though difficult if cervical or upper thoracic GI tract