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Evaluation of suspected upper gastrointestinal bleeding

Evaluation of suspected upper gastrointestinal bleeding
GI: gastrointestinal; CT: computed tomographic; CTA: computed tomographic angiography; MR: magnetic resonance.
* The presence of both hematemesis and melena suggests that brisk bleeding is present.
¶ Bleeding associated with signs such as hypotension, tachycardia, or orthostatic hypotension.
Δ Consider evaluation with a side-viewing duodenoscope if there are risk factors for hemobilia or hemosuccus pancreaticus; consider CTA (followed by push enteroscopy if the CTA is negative) in patients at risk for an aortoenteric fistula. Conventional angiography is typically performed if the patient remains hemodynamically unstable despite attempts at resuscitation.
​Patients who present with hematemesis do not need to undergo colonoscopy, since hematemesis suggests the bleeding is proximal to the ligament of Treitz. They should proceed directly to an evaluation for small bowel bleeding if upper endoscopy is negative. Colonoscopy is the next step in the evaluation of patients with melena.
§ If the patient becomes hemodynamically unstable following initial resuscitation, conventional angiography can be performed. Patients who present with hematemesis do not need to undergo colonoscopy and can skip this step in the evaluation because hematemesis suggests the bleeding is proximal to the ligament of Treitz.
¥ If the initial endoscopic evaluation was inadequate (eg, fair or poor visualization, failure to reach the cecum), repeat examination should be considered before initiating an evaluation for small bowel bleeding. Refer to UpToDate topic review on suspected small bowel bleeding for details.
‡ If not already done. If the patient remains hemodynamically stable and does not have evidence of aggressive bleeding (eg, ongoing hematochezia), perform a CTA or push enteroscopy (CTA is the initial test of choice if there is concern for an aortoenteric fistula). If the patient becomes hemodynamically unstable following initial resuscitation or has signs of aggressive bleeding, perform conventional angiography.
† If not already done, angiography or CTA may be obtained. If angiography or CTA has been performed and no source is identified, a Meckel's scan should be obtained in younger patients with overt bleeding, unless the only manifestation of bleeding was hematemesis. Surgical exploration is appropriate if no other studies have revealed a source and significant bleeding continues or if there is high suspicion for a small bowel neoplasm.
** If the deep small bowel enteroscopy was incomplete, a video capsule endoscopy study should be obtained, followed by CT enterography or MR enterography if the capsule endoscopy is negative.
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