Introduction to Acute Upper Gastrointestinal Hemorrhage

A 45-year-old male presented with hematemesis and melena. Symptoms began earlier this morning with melena; he most recently developed hematemesis in the emergency room. His past medical history is significant for an open right inguinal hernia repair, moderate alcohol consumption of 2-6 beers per night, and occasional ibuprofen for back pain. On exam, the patient appears anxious, is tachycardic to 120 s, blood pressure is 140/110, respiratory rate of 20 breaths/min, with an O2 saturation of 96% on room air. There is no evidence of scleral icterus, palmar erythema, or abdominal wall varices. His abdomen is obese and non-tender without evidence of ascites or palpable liver or splenomegaly. Digital rectal exam reveals melena without masses or hemorrhoidal disease. His point of care hemoglobin is 11 mg/dL. Two large-bore IVs were placed, and a type and cross was sent. A nasogastric tube was placed, revealing bright-red blood. At this time, his blood pressure drops to 80/58 with an increase in tachycardia to 140. Given the persistent tachycardia, narrowed pulse pressure, and hypotension, the patient received two units of packed red blood cells with an appropriate improvement in vital signs. He was transferred to the surgical intensive care unit where he received two additional units over the next 12 h, for a total 4 units within 24 h. Viscoelastic testing was sent at the time, demonstrating coagulopathy and need for fresh frozen plasma. GI consultation was obtained, and the patient was prepared for upper gastrointestinal endoscopy with a single dose of erythromycin. At endoscopy, he was found to have a large ulcer, Forrest 2a with a visible vessel; this was treated with epinephrine injection and clipping with adequate hemostasis. He went on to recover in the SICU while remaining on proton-pump inhibitor therapy without further signs of hemorrhage.