80% of GI bleeding will stop spontaneously if the fluid resuscitation is adequate.

Melena develops when at least 100 mL of blood have been lost.

Occult-blood positive or coffee-ground emesis = 5-10 mL blood loss

Orthostasis is defined as a >10-point rise in pulse when the patient goes from the supine to the standing or sitting position (wait for 1 min). It is also defined as a >20-point drop in SBP on a change in position. It indicates a 15 to 20% blood loss.

Tachycardia (HR>100/min) or hypotension indicates a >30% blood loss

Rx

Packed cells (PRBCs) if hematocrit (Hct) < 30, with older patients; comorbid disease such as CAD.

If young, you can watch until Hct <20 - 25

Fresh Frozen Plasma (FFP) if elevated PT or INR and actively bleeding

Platelets if count <50 and actively bleeding

Octreotide for variceal bleeding

Banding is preferred to sclerotherapy

If still not responding, then do TIPS

the most common, long-term complication of TIPS is worsening of hepatic encephalopathy

Propranolol to prevent subsequent episodes of bleeding. NO use for current active bleeding.

If there is a history of AAA repair in the past 6 months to a year, think about an aortoenteric fistula

Dx

If endoscopy does not reveal the exact bleeding source, then a nuclear bleeding scan can be done, which can detect low volume bleeds 0.1-0.5 mL/min.

Angiography is rarely used and it needs a higher volume of blood loss >0.5 mL/min compared with the tagged nuclear scan

capsule endoscopy allow visualization to small bowel bleeding