Examqo › Examqo library › Internal medicine › Gastroenterology and hepatology · IMLE
Upper gastrointestinal bleeding (non-variceal)
Stabilise first (fluids and restrictive transfusion), assess risk (Glasgow-Blatchford), give a PPI and perform endoscopy within 24 hours; the decision on endoscopic therapy for an ulcer is set by its appearance (Forrest).
Why it matters in the exam
Upper bleeding questions present haematemesis or melaena, often in a patient taking NSAIDs, aspirin or anticoagulants. The candidate must order the steps: two large-bore cannulas, fluids, and blood transfusion only when haemoglobin is below 7 g/dL (and below 8 in a patient with heart disease). A patient with a Glasgow-Blatchford score of 0–1 can be discharged for outpatient work-up. Before endoscopy an intravenous PPI is given, and erythromycin can be used to clear blood from the stomach and improve the view.
After endoscopy the question is what to do with an ulcer by Forrest class: active bleeding (Ia, Ib) or a visible vessel (IIa) — combined endoscopic therapy and high-dose PPI for 72 hours; an adherent clot (IIb) — consider removal and treatment; a flat spot (IIc) or a clean base (III) — no endoscopic therapy, oral PPI and early discharge. For rebleeding a second endoscopy is done, and if it fails — catheter embolisation or surgery. Every ulcer patient is tested and treated for H. pylori, and aspirin given for secondary prevention is restarted as early as possible because stopping it raises cardiovascular mortality.
Key points
- Stabilise: two large-bore cannulas, fluids, transfusion when Hb is below 7 g/dL.
- Glasgow-Blatchford 0–1 → discharge with outpatient work-up.
- Intravenous PPI and endoscopy within 24 hours.
- Forrest Ia, Ib, IIa → endoscopic therapy and high-dose PPI for 72 hours; IIc and III → oral PPI.
- H. pylori, stop NSAIDs and restart secondary-prevention aspirin early.
Summary table
| Step | Tool / threshold | Action | Exam note |
|---|---|---|---|
| Risk assessment | Glasgow-Blatchford 0–1 | Discharge with outpatient work-up | A high BUN to creatinine ratio points to an upper bleed |
| Transfusion | Hb below 7 g/dL (heart disease: below 8) | Restrictive transfusion | Liberal transfusion raises rebleeding |
| Before endoscopy | Any patient with significant bleeding | Intravenous PPI; erythromycin 250 mg | Endoscopy within 24 hours after stabilisation |
| Forrest Ia, Ib, IIa | Active bleeding or visible vessel | Endoscopic therapy + high-dose PPI for 72 hours | High risk of rebleeding |
| Forrest IIb | Adherent clot | Consider removal and treatment | Intermediate risk |
| Forrest IIc, III | Flat spot or clean base | Oral PPI, early discharge | No endoscopic therapy needed |
Free exam questions
בן 75 ., ללא מחלות רקע מתאשפז בגלל דמם רקטלי שהחל ביום פנייתו. בבדיק:ה חיוור, ל"ד 80/40 ממ״כ דופק 110 ,לדקה סטורציה 97% באויר חדר , בטן רכה ללא רגישות ב.מישוש, בבדיקה רקטלית דם טרי במעבדה: המוגלובין 7 גר׳/ד״ל (לפני חודש המוגלובין 12 )גר׳/ד״ל . החולה מטופל ב ,נוזלים ומנת דם ולחץ הדם עולה ל- 110/70 ממ״כ ?איזו בדיקה יש לבצע כעת. (the question as examined, in Hebrew)
- א. קולונוסקופיה
- ב. גסטרוסקופיה
- ג. CT angio של ה בטן
- ד. מיפוי כדוריות אדומות
Male, 68 years of age, undergoes an evaluation while hospitalized due to epigastric abdominal pain and melena for about a week. Due to osteoarthritis, he is treated with Ibuprofen, and this is the only medication he is receiving. On physical examination, BP is 110/60 mmHg, and pulse is 105 per minute. Other vital signs are in the normal range. Upon abdominal examination, there is epigastric tenderness without rebound. Rectal examination - no blood in the stool. Laboratory: hemoglobin 10 gr/dL. Treatment was started with intravenous 0.9% saline, combined with intravenous administration of a proton pump inhibitor (PPI). What will be the next step to advance the diagnosis?
- A. Video Capsule Endoscopy
- B. Colonoscopy
- C. CT angiography
- D. Upper endoscopy
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Medical licensing exam (IMLE), Internal medicine, Emergency medicine, General surgery, Geriatrics, Public health.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding, 2021 — Risk assessment, pre-endoscopic and endoscopic management of ulcer bleeding
- ESGE Guideline: Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage, 2021 — Transfusion thresholds, PPI therapy and Forrest classification
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Gastrointestinal Bleeding
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.