Upper gastrointestinal bleeding is hemorrhage arising from any site between the mouth and the ligament of Treitz. It may be microscopic, silently lowering blood counts, or massive, producing dramatic visible blood loss that endangers life within minutes. Recognizing the spectrum of presentations allows rapid triage, adequate resuscitation, and targeted endoscopic therapy.
- Key visual clues
• Hematemesis: vomiting red liquid or clots signals brisk arterial bleeding; when gastric acid acts for minutes the material turns “coffee-ground.”
• Melena: black, tarry, foul-smelling stool that sticks to porcelain; at least 50 mL of upper-tract blood is required to produce this change, but melena can continue for 2–3 days after bleeding stops.
• Nasogastric aspiration: blood-stained return confirms ongoing hemorrhage; clear bile-stained fluid reduces but does not exclude a duodenal source. - Symptoms related to blood volume loss
• Postural dizziness or frank syncope on standing: suggests ≥15 % circulating volume depletion.
• Resting tachycardia >100 beats/min and orthostatic drop >20 mmHg systolic are early compensatory signs.
• Hypotension, cold clammy skin, delayed capillary refill, and falling urine output mark hemorrhagic shock (>30 % loss).
• Thirst, agitation, and air-hunger may precede measurable hypotension, especially in younger patients. - Subtle or chronic presentations
• Iron-deficiency anemia: fatigue, pallor, brittle nails, or pica in patients who deny visible bleeding; sometimes the only clue to a slowly oozing gastric neoplasm or large hiatal erosion.
• Positive fecal occult blood test discovered during routine colorectal screening. - Associated features suggesting specific causes
• Epigastric pain relieved by food or antacids: peptic ulcer.
• Severe retching followed by longitudinal mucosal tear at the cardia: Mallory-Weiss syndrome.
• Profuse hematemesis in a patient with stigmata of chronic liver disease (spider nevi, ascites, splenomegaly): ruptured gastro-esophageal varices.
• Recent heavy non-steroidal anti-inflammatory drug, aspirin, or anticoagulant use: erosive gastropathy or duodenopathy.
• History of aortic graft surgery: consider aorto-enteric fistula. - Red-flag combinations demanding immediate intervention
Syncope plus any witnessed hematemesis, melena accompanied by systolic blood pressure <90 mmHg, continuous fresh blood via nasogastric tube, or mental confusion with cool peripheries indicate the need for urgent large-bore intravenous access, volume resuscitation, and expedited endoscopy.
Summary table
| Sign/Symptom | Typical volume loss | Next step |
|---|---|---|
| Coffee-ground vomitus | 100–300 mL | Urgent gastroscopy within 24 h |
| Fresh hematemesis with clots | >500 mL often | Large-bore IV, cross-match 4–6 units, ICU bed |
| Melena without shock | 50–200 mL | Monitor vitals every 30 min, Hb at 6 h intervals |
| Orthostatic drop | ≥15 % | Rapid crystalloid, set transfusion trigger Hb <70 g/L |
| Syncope, hypotension, tachypnea | ≥30 % | Activate massive transfusion protocol, secure airway |