GI bleed can be upper or lower GI bleed. Upper GI bleed includes hematemesis (blood in vomitus and/or from the mouth), and Malena (black stool), while lower GI bleed can be frank blood or occult bleeding. Because patients often use vague terms when describing GI bleeding (such as “I vomited a black color material,” “I am coughing blood,” and “I have blood when I wipe or use the bathroom”), a clinician must clarify the chief complaint early in the evaluation process to avoid going down the wrong path.
Upper GI bleed from the mouth (hematemesis) is often a life-threatening situation, and must be managed quickly, regardless of the etiology. Most common pathologies giving rise to this situation include acute esophageal tear, such as Mallory Weis tear, and esophageal variceal bleed. Upper GI bleed presenting in the form of Malena may represent a more insidious process. Lower GI bleed may result from a variety of causes, some of which are quite benign or self-limiting, while other causes are uncommon and require an exhaustive work up and management. Acute mesenteric ischemia can present as an urgent/emergent situation if the bleeding is extensive or if there is extensive mesenteric involvement. This clinical mind map is organized based upon above the descriptions of these groups of differentials.
Urgent/emergent situations are reflected in abnormal vital signs and a patient’s appearance of distress.
Weighing and removing anchor bias involves asking high yield questions and then medium yield questions as listed on the clinical mind map. An appropriate physical exam and lab tests and/or imaging help a clinician arrive at the correct diagnosis. Usually a direct endoscopic evaluation in the form of an upper endoscopy and a colonoscopy constitute part of a routine work up. A complete blood count and additional labs specific to individual diagnoses must be drawn based upon the index of suspicion for these diagnoses.