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Make the Diagnosis: Upper Gastrointestinal Bleed

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Prior Probability of an Upper Gastrointestinal Bleed

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Among patients who present with a gastrointestinal hemorrhage, an upper gastrointestinal bleed (UGIB) is more likely (incidence 63%, 95% CI, 51-73%) than a lower gastrointestinal bleed (LGIB). Among patients with UGIB, 36% (95% CI, 29-44%) require urgent intervention for severe bleeding.

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Population in Whom UGIB Should Be Considered

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Patients with gastrointestinal bleeding may present with visual evidence of blood loss such as hematemesis, hematochezia, melena, or coffee-ground emesis. Patients may not always reliably recognize melena as visual evidence of bleeding. A UGIB source should be considered in all patients with evidence of gastrointestinal blood loss.

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Assessing the Likelihood of UGIB in Patients With Gastrointestinal Bleeding

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Patients with a prior UGIB, younger patients (age < 50), or those with cirrhosis are more likely to have a UGIB than an LGIB (see Table 87-1). Although not all black stools represent melena, patients who report black stools are much more likely to have a UGIB source. The physician should inspect a stool sample when the patient has a GIB. Confirming melena is the most useful finding for identifying patients mostly likely to have a UGIB. When clots are seen in the stool, the patient is much less likely to have a UGIB. Because a negative nasogastric lavage cannot rule out a UGIB or an UGIB requiring intervention, many experts do not advocate for its use as a routine diagnostic test, and they instead favor endoscopy.

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Table 87-1.Useful Findings for Assessing the Likelihood of a UGIB
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Assessing the Likelihood That a Patient With Gastrointestinal Bleeding Is Having Severe Bleeding

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The severity of the bleeding guides the need and urgency of subsequent procedures. A rapid pulse (> 100/minute) or significant anemia (hemoglobin < 8 g/dL) are the most useful findings to identify the patient suffering from severe bleeding (Table 87-2). Up to 22% of patients will have a Blatchford score of 0 (Table 87-3), and these patients are highly unlikely to have a severe hemorrhage.1-2 The Blatchford score can be determined without nasogastric lavage.

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Table 87-2.Useful Findings for Assessing the Likelihood of a Severe UGIB

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