Guide — Gastrointestinal
Upper GI Bleeding
Upper GI bleeding (UGIB) originates proximal to the ligament of Treitz — esophagus, stomach, or duodenum. It presents with hematemesis, coffee-ground emesis, or melena and carries significant mortality risk.
12 min read · Gastrointestinal
Educational use only. This content is intended for nursing students and exam preparation. Clinical decisions require licensed professional judgment and institutional protocols. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Common Causes
| Cause | Key Features |
|---|---|
| Peptic ulcer disease (PUD) | Most common cause (40–50%). H. pylori and NSAIDs are major risk factors. Duodenal ulcers most common. |
| Esophageal/gastric varices | Portal hypertension from cirrhosis. Massive, life-threatening hemorrhage. High rebleed rate. |
| Mallory-Weiss tear | Mucosal tear at gastroesophageal junction from forceful vomiting or retching. Often self-limited. |
| Esophagitis/gastritis | Inflammation from acid, NSAIDs, alcohol, bile reflux. Usually less severe bleeding. |
| Dieulafoy lesion | Large submucosal artery that erodes through mucosa. Rare but causes massive hemorrhage. |
| Gastric cancer | Painless bleeding, weight loss, anemia. Consider in patients >50 with new symptoms. |
| GAVE (gastric antral vascular ectasia) | "Watermelon stomach" — chronic blood loss, anemia. Associated with cirrhosis and autoimmune diseases. |
Clinical Presentations
Hematemesis
- ✦Vomiting of bright red blood = active, brisk bleeding
- ✦Coffee-ground emesis = blood altered by gastric acid (slower/older bleed)
- ✦Indicates source proximal to ligament of Treitz
- ✦May accompany or precede melena
Melena
- ✦Black, tarry, foul-smelling stool
- ✦Requires >50–100 mL blood in upper GI tract
- ✦Blood oxidized by gut bacteria during transit
- ✦Can persist for days after bleeding stops
Hematochezia in UGIB
- ✦Bright red rectal blood can occur with massive UGIB
- ✦Rapid transit — blood passes before oxidation
- ✦Indicates hemodynamically significant, high-volume bleed
- ✦Requires urgent endoscopy
Occult Bleeding
- ✦No visible blood — detected by fecal occult blood test (FOBT)
- ✦Presents with iron deficiency anemia, fatigue
- ✦Chronic slow bleeding from ulcer, cancer, or vascular lesion
- ✦Positive FOBT warrants further workup
Assessment Findings
Rapid assessment of hemodynamic stability is the first priority. Assess for signs of shock before any diagnostic testing.
| Parameter | Finding in Significant Bleed | Clinical Significance |
|---|---|---|
| Blood pressure | Hypotension (SBP <90 mmHg) | Hemodynamic shock — immediate resuscitation needed |
| Heart rate | Tachycardia (HR >100) | Compensatory response to volume loss |
| Orthostatic changes | Drop in BP ≥20 mmHg standing/sitting | Significant volume depletion (≥500 mL loss) |
| Skin | Pallor, diaphoresis, cool extremities | Peripheral vasoconstriction — shock state |
| Urine output | Oliguria (<0.5 mL/kg/hr) | Renal hypoperfusion from volume loss |
| Mental status | Anxiety, confusion, decreased consciousness | Cerebral hypoperfusion — severe hemorrhage |
| Hemoglobin/Hct | May be normal initially (equilibration takes 6–24 hrs) | Initial labs can underestimate blood loss — recheck |
| BUN:Creatinine ratio | >20:1 without renal disease | Blood in GI tract digested as protein — raises BUN selectively |
Treatment Overview
Hemodynamic resuscitation
Establish two large-bore (18G or larger) IV lines. Aggressive IV fluid resuscitation with NS or LR. Transfuse pRBCs for Hgb <7 g/dL (or <8 g/dL in cardiovascular disease). Transfuse platelets and FFP for coagulopathy or variceal bleeding. Activate massive transfusion protocol for ongoing hemorrhage.
Acid suppression (PUD/ulcer bleeding)
High-dose IV proton pump inhibitor (PPI): IV pantoprazole or omeprazole infusion. PPI reduces rebleed risk and improves endoscopic hemostasis. Begin before endoscopy (don't delay scope for PPI loading).
Variceal-specific therapy
IV octreotide (somatostatin analogue): reduces portal pressure and splanchnic blood flow — start immediately if varices suspected. Continue for 3–5 days. Antibiotic prophylaxis — IV ceftriaxone 1 g/24h is the current antibiotic of choice (oral quinolones like norfloxacin are an older alternative now limited by resistance). Reduces bacterial translocation and SBP risk; continue up to 7 days. TIPS or balloon tamponade for refractory variceal bleeding.
Urgent upper endoscopy (EGD)
Perform within 24 hours (within 12 hours for hemodynamically unstable patients). Endoscopic hemostasis: epinephrine injection, thermal coagulation, clipping, banding (varices). Determines source, risk-stratifies rebleed, provides treatment.
Monitoring and follow-up
ICU or monitored bed for high-risk patients. Serial CBC every 4–6 hours. Trend Hgb — falling Hgb suggests ongoing bleed. NPO until after endoscopy. Nasogastric tube may be placed (controversial) for gastric lavage or lavage before scope.
Nursing Priorities
Assess hemodynamic stability immediately
Vital signs every 15 minutes in active bleed. Monitor BP, HR, orthostatic changes, skin perfusion, and mental status. Call provider immediately for SBP <90, HR >120, or altered mental status.
Establish IV access and prepare for resuscitation
Two large-bore peripheral IVs (18G or larger). Draw labs: CBC, BMP, coagulation studies, type & screen/crossmatch. Anticipate blood product transfusion — verify consent and blood type.
Maintain NPO status
NPO until after endoscopy. Remove oral medications. Ensure IV access for all medications. Communicate NPO status to all team members.
Prepare for emergency endoscopy
Ensure consent obtained. Remove dentures. Position patient left lateral decubent. Have suction available. Monitor airway during procedure.
Monitor urine output and fluid balance
Insert Foley catheter for accurate output. Target UO ≥0.5 mL/kg/hr. Document strict I&O. Notify provider for oliguria.
Assess for rebleed signs
Serial vital signs, Hgb trends. New hematemesis, increasing melena, hemodynamic deterioration = rebleed. Recurrent variceal bleeding is a high-mortality event.
NCLEX Pearls
- ✦Upper GI bleeding = source proximal to ligament of Treitz (esophagus, stomach, duodenum). Lower GI = below that point.
- ✦First action in GI bleed: assess hemodynamic stability — airway, breathing, circulation before any diagnostic workup.
- ✦BUN:Creatinine ratio >20:1 in GI bleed: blood is digested as protein and raises BUN — classic NCLEX clue for upper GI source.
- ✦Melena (black tarry) = upper GI bleed. Hematochezia (bright red blood) = usually lower GI, but can indicate massive UGIB.
- ✦Hemoglobin may be normal initially after acute bleed — takes 6–24 hours for hemodilution to equilibrate. Don't be falsely reassured.
- ✦Esophageal varices = portal hypertension complication — octreotide is the first-line pharmacologic treatment.
- ✦PPI therapy: give before endoscopy in suspected peptic ulcer bleed. It helps stabilize clots and improves endoscopic success.
- ✦Two large-bore IVs before anything else in hemodynamically unstable GI bleed — not central line first (too slow to place in emergency).
- ✦Variceal bleed + antibiotics: prophylactic antibiotics reduce mortality by preventing bacterial translocation and spontaneous bacterial peritonitis. IV ceftriaxone 1 g/24h (up to 7 days) is the current first-line agent (AASLD/Baveno VII/ESGE); oral quinolones (norfloxacin) are an older alternative now limited by widespread resistance and are no longer available on most US formularies.
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with American College of Gastroenterology (ACG) / AGA · ASPEN (nutrition support). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →