Rationale

Upper gastrointestinal bleeding can manifest either as hematemesis or melena. It always warrants careful and urgent evaluation, investigation, and treatment. The management depends on the amount of blood loss, the likely cause of the bleeding, and the underlying health of the patient.

Causal Conditions

(list not exhaustive)

1. Ulcerative or erosive processes

   1. Peptic ulcer disease

   2. Esophagitis

   3. Gastritis

2. Portal hypertension

3. Trauma (e.g., Mallory-Weiss tear)

4. Tumors

Key Objectives

Given a patient with hematemesis or melena, the candidate will diagnose the cause, severity, and complications, and will initiate an appropriate management plan. In particular, the candidate will determine and manage the hemodynamic status of the patient and resuscitate if necessary.

Enabling Objectives

Given a patient with upper gastrointestinal bleeding, the candidate will

1. list and interpret critical clinical findings, including

   1. the cause of the bleeding, as determined by clinical history;

   2. the results of an appropriate physical examination notably aimed at assessing the patient’s hemodynamic stability;

   3. indications of a high likelihood of rebleeding;

2. list and interpret critical clinical investigations, including

   1. endoscopy;

   2. laboratory and diagnostic imaging as appropriate;

3. construct an effective management plan, including

   1. resuscitation of the hemodynamically unstable patient;

   2. medical treatment as appropriate;

   3. employment of endoscopic procedures as needed;

   4. determining whether the patient needs immediate specialized care (gastroenterology, general surgery, or intensive care unit).

   5. instituting preventive measures or treatments to avoid rebleeding (e.g. treatment of H. pylori)