Upper Gastrointestinal Bleed — History and Physical Exam — Clinical Pathway: Emergency Department, ICU and Inpatient

Upper Gastrointestinal Bleed Clinical Pathway — Emergency Department, ICU and Inpatient

History and Physical Exam

Differential Diagnosis

History
  • Determine likely source of bleeding:
    • Swallowed maternal blood with breastfeeding
    • Oral trauma
    • Epistaxis
    • Ingestion of foods with red dye
    • Ensure no history of hemoptysis/pulmonary source
  • Time of symptom onset
  • Estimate of blood loss:
    • Streaks vs. quarter-sized clots
    • Melena
    • Symptomatic anemia:
      • Fatigue, orthostasis, syncope
  • Related antecedent events:
    • Trauma, ingestion, FB, infection
  • Medications:
    • NSAID use, anti-thrombotic medication
  • Significant pre-existing conditions:
    • Liver disease
    • History of varices
    • Prior history of intestinal surgery, especially bowel resection w/ anastomosis
    • Peptic ulcer disease
    • History UGI bleed
Physical Exam
  • Assess intravascular volume status:
    • MS, pallor
    • Tachycardia, especially if HR > 20 bpm from mean HR for age
    • Prolonged capillary refill
    • Hypotension for age
  • Abdominal tenderness, evidence of peritoneal signs
  • Hepatomegaly and splenomegaly
  • Rectal exam:
    • History of melena or bright red blood per rectum to assess for visible lower GI source such as hemorrhoid, fissure, or blood/melena on digital rectal exam

Age-related Vital Sign Targets

Age Heart Rate SBP MAP DBP
31 days to < 1 year 100-160 > 65 > 45 > 30
1 year to < 2 years 90-160 > 70 > 50 > 35
2 to < 6 years < 140 > 75 > 50 > 40
6 to < 13 years < 130 > 85 > 60 > 45
≥ 13 years < 110 > 90 > 65 > 50