diverticulosis is most common (Table 30-2). Less common

causes include pseudomembranous colitis, infectious diar ­

rhea, aortoenteric fistula, radiation colitis, mesenteric

ischemia, and Meckel diverticulum.

CLINICAL PRESENTATION

..... History

In most cases, patients will report hematemesis, coffeeground emesis, hematochezia, or melena. The duration

and frequency of these symptoms should be elicited. For

hematemesis, it is important to determine whether blood

was present initially or appeared after several episodes of

vomiting. The latter history suggests a Mallory-Weiss tear.

A history compatible with cirrhosis (chronic alcohol use,

hepatitis, IV drug use) suggests varices. These patients

may also have a coagulopathy, making control of hemorrhage more difficult. When bleeding has been slow but

chronic, the patient may present with lightheadedness,

fatigue, chest pain, or shortness of breath owing to anemia

without any knowledge of GI bleeding. Patients with pep ­

tic ulcer disease may report epigastric abdominal pain

related to eating. Agents that increase the risk of peptic

ulcer disease include nonsteroidal anti-inflammatory

drugs (NSAIDs), aspirin, and cigarettes. Elderly patients

with acute hemorrhage may initially present with syncope

or near-syncope.

..... Physical Examination

Vital signs should be obtained immediately. When abnormalities are present, treatment is frequently necessary

before obtaining a thorough history. Tachycardia and

hypotension indicate hypovolemic shock and require

immediate resuscitation. Cool, pale, and clammy skin is

evidence of anemia or shock. The abdomen should be

thoroughly examined, noting areas of tenderness or peri tonitis. Rectal examination should be performed with

Hemoccult testing. The presence of hemorrhoids should

be documented. They may or may not be the source of

lower GI bleeding. Examination should also elicit any evidence of the stigmata of cirrhosis including ascites, spider

angioma, j aundice, or palmar erythema.

DIAGNOSTIC STUDIES

..... Laboratory

Complete blood count, electrolytes, renal function, and

coagulation studies should be obtained. It is important to

remember that a normal hemoglobin value does not rule

out a massive acute hemorrhage. Compensatory hemodilution may not occur for 2-3 hours. Blood bank should be

contacted for immediate type and screen. Blood products

should be ordered for patients with unstable vital signs or

significant blood loss. Upper GI bleeding may elevate

blood urea nitrogen because of the digestion and absorption of hemoglobin.

.... Imaging

Upright chest x-ray is indicated in patients with suspicion

of perforation or aspiration. The presence of free air under

the diaphragm is diagnostic of perforation and is a surgical

emergency. Routine imaging otherwise offers little clinical

value in GI bleeding .

..... Electrocardiogram

An electrocardiogram should be obtained on patients with

risk factors for coronary artery disease, patient with known

heart disease,