What is the initial assessment and management for a patient presenting with gastrointestinal bleed?

History of Present Illness for Gastrointestinal Bleeding

Chief Complaint and Bleeding Characteristics

Document the specific manifestation of visible blood loss: hematemesis (vomiting blood), melena (black tarry stools), or hematochezia (bright red blood per rectum), as these presentations guide localization of the bleeding source. 1

• Hematemesis or melena strongly suggests upper GI bleeding, while hematochezia typically indicates lower GI bleeding—however, hematochezia with hemodynamic instability may represent a briskly bleeding upper GI source. 2, 3
• Quantify the amount and frequency of bleeding episodes, including number of episodes in the past 24 hours and estimated volume. 1
• Document timing of first bleeding episode and whether bleeding is ongoing or has stopped. 4

Hemodynamic Status Assessment

Calculate the shock index (heart rate divided by systolic blood pressure) immediately—a value >1 defines hemodynamic instability and mandates urgent intervention rather than routine endoscopy. 1, 2

• Record vital signs including heart rate, blood pressure (both supine and orthostatic if safe), and presence of syncope or presyncope. 4, 2
• Document signs of hemodynamic compromise: tachycardia (>100 bpm), hypotension (systolic BP <100 mmHg), orthostatic changes, syncope, and pallor. 4, 1
• Note any evidence of ongoing bleeding during initial evaluation, including gross blood on rectal examination within the first 4 hours. 4

Transfusion and Resuscitation Requirements

• Document number of blood transfusions required, as patients requiring ≥4 units of red cells have 20% mortality compared to 3.4% overall. 1, 5
• Record initial hemoglobin and hematocrit values, with specific attention to hemoglobin <70 g/L (22 points on risk stratification) or hematocrit <35%. 4, 2
• Note any decrease in hematocrit ≥6% or hemoglobin drop of >20% during evaluation. 4

Medication History Critical to Bleeding Risk

• Document aspirin use (associated with severe bleeding), warfarin therapy (requiring INR documentation), and other anticoagulants or antiplatelet agents. 4, 5
• Record whether aspirin is for primary versus secondary cardiovascular prevention, as management differs. 5
• Note NSAID use, particularly in patients with suspected diverticular or angioectasia bleeding. 3
• Document current INR if on warfarin and platelet count if on antiplatelet therapy. 2, 5

Comorbid Conditions Affecting Mortality

Mortality in GI bleeding relates primarily to comorbidities rather than exsanguination, so document all active medical conditions meticulously. 1, 5

• Record presence and severity of cardiovascular disease, as this affects transfusion thresholds (Hb trigger 80 g/L vs 70 g/L). 1, 2
• Document liver disease or cirrhosis, which dramatically increases mortality risk. 6
• Note presence of >2 active comorbid conditions, which independently predicts severe bleeding. 4
• Record any unstable comorbid disease and erratic mental status (components of BLEED classification). 4

Prior Bleeding History and Risk Factors

• Document any previous episodes of GI bleeding, including timing and identified source. 5
• For suspected lower GI bleeding, note history of diverticulosis (75% resolve spontaneously, but 14-38% recurrence rate). 4
• Record history of peptic ulcer disease, varices, or known vascular lesions. 3, 6
• Document any prior endoscopic or surgical interventions for GI bleeding. 4

Coagulation Status

• Record baseline coagulation studies including PT/INR and platelet count. 2
• Note elevated prothrombin time (component of BLEED classification predicting adverse outcomes). 4
• Document any known bleeding disorders or coagulopathy. 2

Abdominal Examination Findings

• Document presence or absence of abdominal tenderness, as a nontender abdomen is an independent correlate of severe bleeding. 4
• Record findings on digital rectal examination, including presence of gross blood, melena, or hematochezia. 4, 5

Risk Stratification Score Calculation

• For lower GI bleeding in stable patients, calculate the Oakland score (incorporating age, gender, prior LGIB, rectal exam findings, heart rate, systolic BP, and hemoglobin)—a score ≤8 indicates safe discharge for outpatient investigation, while >8 requires admission. 2, 5
• For upper GI bleeding, document Glasgow-Blatchford score components if applicable. 7