A 22-year-old woman comes to the emergency department because of chest and epigastric pain that started just after vomiting 30 minutes ago. She does not take any medications and does not drink alcohol or smoke cigarettes. While in the emergency department, the patient experiences two episodes of forceful, bloody emesis. Her temperature is 99.1°F (37.3°C), pulse is 110/minute, and blood pressure is 105/60 mm Hg. Physical examination shows dental enamel erosion and calluses on the dorsal aspect of her right hand. There is tenderness to palpation in the epigastrium. An x-ray of the chest is normal. Further evaluation of this patient is most likely to show which of the following findings?

Mucosal lacerations at the gastroesophageal junction

Rupture of the distal esophagus

Friable mass in the distal esophagus

Dilated veins in the esophageal submucosa

A 14-month-old boy has iron-deficiency anemia refractory to iron therapy. His stool is repeatedly positive for occult blood. The parents bring the child to the emergency room after they notice some blood in his stool. Which of the following is the diagnostic gold standard for this patient's most likely condition?

Technetium-99m pertechnetate scan

A 70-year-old man comes to the clinic for generalized fatigue. He says that he is more tired than before and has difficulty catching his breath while walking upstairs. He feels tired quickly doing his usual activity such as gardening and shopping. He does not have any symptoms of fever, change in bowel habits, abdominal pain, rectal bleeding, or weight loss. His appetite is normal. His last colonoscopy was done 10 years ago and it was normal. His blood pressure is 116/74 and heart rate is 87/min. On physical examination, his conjunctivae are pale. A routine blood test shows iron deficiency anemia with hemoglobin of 10 gm/dL. His stool is positive for occult blood. He is then sent for a colonoscopy (image is shown). What is the most likely diagnosis for the above condition?

Hereditary hemorrhagic telangiectasia

A 57-year-old man is brought to the emergency department by his family because of several episodes of vomiting of blood in the past 24 hours. He has a history of alcoholic cirrhosis and is being treated for ascites with diuretics and for encephalopathy with lactulose. His vital signs include a temperature of 36.9°C (98.4°F), pulse of 85/min, and blood pressure of 80/52 mm Hg. On examination, he is confused and unable to give a complete history. He is noted to have jaundice, splenomegaly, and multiple spider angiomas over his chest. Which of the following is the best initial management of this patient?

Combined vasoactive and endoscopic therapy

Transjugular intrahepatic portosystemic shunt (TIPS)

A 65-year-old patient presents with acute left lower quadrant abdominal pain and is diagnosed with diverticulitis. Which of the following is most likely to have prevented this patient's condition?

Different antibiotic regimen for bronchitis

Sitz baths and nifedipine suppositories

A 72-year-old male with a past medical history significant for aortic stenosis and hypertension presents to the emergency department complaining of weakness for the past 3 weeks. He states that, apart from feeling weaker, he also has noted lightheadedness, pallor, and blood-streaked stools. The patient's vital signs are stable, and he is in no acute distress. Laboratory workup reveals that the patient is anemic. Fecal occult blood test is positive for bleeding. EGD was performed and did not reveal upper GI bleeding. Suspecting a lower GI bleed, a colonoscopy is performed after prepping the patient, and it is unremarkable. What would be an appropriate next step for localizing a lower GI bleed in this patient?

Technetium-99 labelled erythrocyte scintigraphy

GI bleeding (upper and lower) for USMLE Step 2 CK: High-Yield Internal Medicine Lessons

GI Bleeding - The First Response

Initial Assessment (ABCs): Secure airway, ensure breathing, manage circulation.
IV Access: Establish 2 large-bore (≥18 gauge) peripheral IV lines.
Labs: CBC, CMP, PT/INR, PTT, type & crossmatch.
Resuscitation:
- Begin IV crystalloids (Normal Saline / Lactated Ringer's).
- Transfuse packed red blood cells (PRBCs) for Hemoglobin < 7 g/dL (or < 9 g/dL in CAD).
- Correct coagulopathy (e.g., FFP for INR > 1.5; platelets if < 50,000/μL).

⭐ A BUN/Creatinine ratio > 20 strongly suggests an Upper GI Bleed source due to the digestion and absorption of blood proteins.

Algorithm for Initial Management of Acute GI Bleeding

Upper GI Bleed - Above the Ligament

Definition: Bleeding proximal to the Ligament of Treitz.
Etiology:
- Peptic Ulcer Disease (PUD) is most common (>50%).
- Esophageal/Gastric Varices (secondary to portal hypertension).
- Mallory-Weiss Tears (forceful retching).
- Erosive gastritis/esophagitis (NSAIDs, alcohol).
- Malignancy.
Presentation:
- Hematemesis (bright red or coffee-ground emesis).
- Melena (black, tarry stools).
- Anemia symptoms; hemodynamic instability in severe bleeds.
Management:
- Stabilize: 2 large-bore IVs, fluids, transfuse if Hb < 7 g/dL.
- Medicate: IV Proton Pump Inhibitor (PPI). Consider octreotide for varices.
- Scope: EGD within 24 hours for diagnosis & intervention.

⭐ A BUN/Cr ratio > 20 suggests an upper GI source due to digestion and absorption of blood proteins.

Upper GI Bleeding: Anatomy & Ligament of Treitz

Lower GI Bleed - Below the Divide

Etiology: Most common is Diverticulosis (painless, arterial bleed). Others: Angiodysplasia (painless, venous), IBD (Crohn's/UC), malignancy, hemorrhoids, ischemic colitis.
Presentation: Hematochezia (bright red blood per rectum). Always rule out a brisk upper GI bleed first (e.g., NG tube lavage).

Management Pearls:
- Colonoscopy: Primary diagnostic and therapeutic tool.
- Tagged RBC Scan: Detects slow bleeds (≥0.1 mL/min).
- CTA: Detects faster bleeds (≥0.5 mL/min); better localization than RBC scan.

⭐ Most diverticular bleeds (~80%) resolve spontaneously. Angiodysplasia is a common cause of obscure GI bleeding in the elderly.

Management - Tools & Tactics

Resuscitation: 2 large-bore IVs, O₂, crystalloids. Transfuse for Hb < 7 g/dL (< 9 in CAD).
UGIB: IV PPI drip. Octreotide for suspected varices. Endoscopy for diagnosis & therapy (clipping, cautery).
LGIB: Colonoscopy is primary tool. For ongoing bleeding, use CTA or tagged RBC scan.
Refractory Bleeds: Angiographic embolization, TIPS (variceal), or surgery.

⭐ IV PPI before endoscopy can decrease high-risk stigmata and the need for endoscopic therapy, but does not reduce rebleeding, surgery, or mortality.

Angiographic embolization of bleeding mesenteric artery

High‑Yield Points - ⚡ Biggest Takeaways

Peptic ulcer disease is the top cause of UGIB; diverticulosis is the most common cause of LGIB.

First, ensure hemodynamic stability with two large-bore IVs before attempting to identify the source.

An elevated BUN/creatinine ratio (>20:1) strongly points to an UGIB.

Endoscopy is the primary diagnostic and therapeutic tool for UGIBs; colonoscopy is used for LGIBs.

Use IV PPIs for ulcer bleeds; use octreotide and antibiotics for suspected variceal bleeding.

Hematochezia with instability can indicate a massive UGIB.

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