What is the most appropriate next step for a young man with severe upper gastrointestinal (GI) bleeding, no history of medical problems, occasional use of nonsteroidal anti-inflammatory drugs (NSAIDs), hypotension, and severe anemia?

Initial Resuscitation with Normal Saline

Begin immediate resuscitation with normal saline (Option A) as the first-line intervention for this young man with severe upper GI bleeding and hypotension. 1

Rationale for Normal Saline First

The priority in severe upper GI bleeding with hypotension is rapid volume resuscitation to restore hemodynamic stability and tissue perfusion. 1 This patient meets criteria for severe bleeding based on:

• Hypotension (systolic BP <100 mm Hg) 1
• Hemoglobin <100 g/L (8.7 g/dL) 1
• Likely tachycardia (pulse >100 bpm based on shock state) 1

Stepwise Resuscitation Algorithm

Step 1: Immediate Crystalloid Resuscitation

• Establish two large-bore IV cannulae in the anticubital fossae 1
• Infuse normal saline rapidly (1-2 liters initially) to achieve:
  • Falling pulse rate 1
  • Rising blood pressure 1
  • Adequate urine output (>30 ml/hour) 1
  • Central venous pressure 5-10 cm H₂O 1

Step 2: Assess Response and Add Blood Products

After initial crystalloid resuscitation, blood transfusion becomes necessary when: 1, 2

• Hemoglobin <100 g/L (10 g/dL) in acute bleeding 1
• Patient remains shocked after 1-2 liters of saline (indicating >20% blood volume loss) 1
• Active hematemesis with shock 1
• Target hemoglobin threshold: 70-80 g/L (7-8 g/dL) for transfusion 2, 3

Step 3: Consider Plasma Expanders

• Only if patient remains shocked after 1-2 liters of crystalloid 1
• This indicates at least 20% blood volume loss requiring more aggressive replacement 1

Why Not Start with Blood Transfusion Alone?

While this patient's hemoglobin of 8.7 g/dL is below the traditional 10 g/dL threshold mentioned in older guidelines 1, and he is hypotensive, immediate volume expansion with crystalloid takes priority because:

• Crystalloid can be infused immediately without waiting for type and crossmatch 1, 2
• Most patients respond to 1-2 liters of saline alone 1
• Modern evidence supports restrictive transfusion thresholds (7-8 g/dL) 2, 3
• Volume depletion, not just anemia, is causing the hypotension 1

Why Not Colloids or Ringer's Lactate with Albumin?

• No evidence supports colloids over crystalloids as first-line therapy 1
• Colloids (plasma expanders) are reserved for persistent shock after crystalloid failure 1
• Ringer's lactate with albumin (Option D) has no established role in acute upper GI bleeding resuscitation 1
• Guidelines specifically recommend normal saline for patients without liver disease 1

Critical Concurrent Management

While initiating normal saline resuscitation: 1, 2, 3

• Insert urinary catheter and monitor hourly urine output 1
• Continuous automated blood pressure and pulse monitoring 1
• Obtain blood for type and crossmatch, complete blood count, coagulation panel 1, 2
• Initiate proton pump inhibitor therapy 2, 3
• Keep patient fasted until hemodynamically stable 1
• Arrange urgent endoscopy within 24 hours 2, 3

Special Consideration for This Young Patient

This young man with only occasional NSAID use likely has NSAID-induced peptic ulcer disease as the bleeding source. 1 His young age and lack of comorbidity are favorable prognostic factors, but the severity of bleeding (hypotension, hemoglobin 8.7 g/dL) mandates aggressive initial resuscitation. 1

The correct answer is A (Normal Saline) as the most appropriate immediate next step, followed by blood transfusion if he remains unstable or meets transfusion thresholds after initial crystalloid resuscitation. 1, 2