title: Does this patient have a severe upper gastrointestinal bleed?
abstract: BACKGROUND
  Emergency physicians must determine both the location and the severity of acute gastrointestinal bleeding (GIB) to optimize the diagnostic and therapeutic approaches.
  
  
  OBJECTIVE
  To identify the historical features, symptoms, signs, bedside maneuvers, and basic laboratory test results that distinguish acute upper GIB (UGIB) from acute lower GIB (LGIB) and to risk stratify those patients with a UGIB least likely to have severe bleeding that necessitates an urgent intervention.
  
  
  METHODS
  A structured search of MEDLINE (1966-September 2011) and reference lists from retrieved articles, review articles, and physical examination textbooks.
  
  
  METHODS
  High-quality studies were included of adult patients who were either admitted with GIB or evaluated in emergency departments with bedside evaluations and/or routine laboratory tests, and studies that did not include endoscopic findings in prediction models. The initial search yielded 2628 citations, of which 8 were retained that tested methods of identifying a UGIB and 18 that identified methods of determining the severity of UGIB.
  
  
  METHODS
  One author abstracted the data (prevalence, sensitivity, specificity, and likelihood ratios [LRs]) and assessed methodological quality, with confirmation by another author. Data were combined using random effects measures.
  
  
  RESULTS
  The majority of patients (N = 1776) had an acute UGIB (prevalence, 63%; 95% CI, 51%-73%). Several clinical factors increase the likelihood that a patient has a UGIB, including a patient-reported history of melena (LR range, 5.1-5.9), melenic stool on examination (LR, 25; 95% CI, 4-174), a nasogastric lavage with blood or coffee grounds (LR, 9.6; 95% CI, 4.0-23.0), and a serum urea nitrogen:creatinine ratio of more than 30 (summary LR, 7.5; 95% CI, 2.8-12.0). Conversely, the presence of blood clots in stool (LR, 0.05; 95% CI, 0.01-0.38) decreases the likelihood of a UGIB. Of the patients clinically diagnosed with acute UGIB, 36% (95% CI, 29%-44%) had severe bleeding. A nasogastric lavage with red blood (summary LR, 3.1; 95% CI, 1.2-14.0), tachycardia (LR, 4.9; 95% CI, 3.2-7.6), or a hemoglobin level of less than 8 g/dL (LR range, 4.5-6.2) increase the likelihood of a severe UGIB requiring urgent intervention. A Blatchford score of 0 (summary LR, 0.02; 95% CI, 0-0.05) decreases the likelihood that a UGIB requires urgent intervention.
  
  
  CONCLUSIONS
  Melena, nasogastric lavage with blood or coffee grounds, or serum urea nitrogen:creatinine ratio of more than 30 increase the likelihood of a UGIB. Blood clots in the stool make a UGIB much less likely. The Blatchford clinical prediction score, which does not require nasogastric lavage, is very efficient for identifying patients who do not require urgent intervention.
authors.affiliation: Department of Medicine, Duke University Medical Center, PO Box 3913, Durham, NC 27710, USA. srygl001@mc.duke.edu
authors.forename: F Douglas
authors.initials: FD
authors.lastname: Srygley
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Gerardo
authors.forename: Tony
authors.initials: T
authors.lastname: Tran
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Fisher
mesh_terms: D000208:Acute Disease; D001769:Blood; D004636:Emergency Service, Hospital; D005243:Feces; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000145:classification* / Q000175:diagnosis*; D006801:Humans; D007441:Intubation, Gastrointestinal; D041741:Lower Gastrointestinal Tract / Q000473:pathology*; D008297:Male; D008551:Melena; D008875:Middle Aged; D010808:Physical Examination; D018570:Risk Assessment; D012720:Severity of Illness Index; D007507:Therapeutic Irrigation; D013927:Thrombosis; D041742:Upper Gastrointestinal Tract / Q000473:pathology*