Esophageal varices that have recently bled have a high risk of rebleeding; therefore, patients should be admitted to a monitored or intensive care area until endoscopy has been performed. Once unleashed, the bleeding from esophageal bleeding can be brisk and can quickly result in hemodynamic instability.

Patients with peptic ulcers can have those ulcers perforate, and the patient will then require emergent surgery. Failure to consider perforation in the differential diagnosis of abdominal pain in a patient with hematemes is will result in a delay in the diagnosis of a surgical abdomen. A bad patient outcome is likely.

Pediatric patients typically have different causes of GI bleeding than adults. Infants with GI bleeding may have conditions such as intussusception that are not seen in adults.

Young patients who appear to have minor GI bleeding should stop taking NSAIDs. Their seemingly minor problem may progress if modifiable risk factors for GI bleeding are not addressed.

Anemia may sufficiently lower the oxygen-carrying capacity of the blood of a patient with pre-existing coronary artery disease to the point that myocardial ischemia or infarction develops. Since there are obvious problems with the administration of aspirin, heparin, thrombolytics, and other treatments for myocardial infarction in the setting of GI bleeding, it is better to treat mild anemias with the transfusion of packed red blood cells before myocardial effects occur.

Some patients are at very high risk for complications associated with GI bleeding. The most lethal is an aortoenteric fistula. Although this can be a primary process, it is more commonly seen in patients who have undergone vascular grafting of their aorta in the past.

Supine tachycardia places a patient at high risk for rebleeding and complications. Missing a simple warning sign like this—especially one that’s almost always well-documented in the medical record—is just asking for trouble.

Assuming that a distal site is the cause of the bleeding without placing this information in the context of the overall clinical picture can be very dangerous. Many patients have external hemorrhoids. This finding, by itself, does not mean that the hemorrhoid is the cause of the bleeding. A much more ominous site may be lurking proximal to an external hemorrhoid.

Unless the patient has hepatic encephalopathy or is in profound hemorrhagic shock, minor GI bleeding is probably not the cause of altered mental status. Other etiologies must be entertained. Shock from any cause can cause a decrease in the blood flow to the intestines and lead to minor GI bleeding as a concomitant effect. Assuming that the major problem is GI bleeding may delay the identification of the true underlying emergency condition.

In any patient with GI bleeding that is anything other than trivial—and certainly in high-risk patients—coordinated care with a gastroenterologist experienced in endoscopy is critical. Close consultation and prompt endoscopy can be life-saving.

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