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usmle step 2 ck

Upper GI Bleeding

Bleeding proximal to the ligament of Treitz, presenting with hematemesis, coffee-ground emesis, melena, or hemodynamic instability

Review date
reviewed 2026-05-04
Reading time
9 min read
Author
Dr Kola Tytler MBBS CertHE MBA MSt MRCGP
Gastroenterology & Hepatologycommonemergency
On this page
Condition details
Gastroenterology & Hepatology
common
9 min read
reviewed 2026-05-04
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About This Page

This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.

Key points

  • Initial management is ABCs, two large-bore IVs, type and crossmatch, CBC/CMP/coags, and resuscitation
  • Transfuse packed RBCs at Hgb <7 g/dL in most patients; consider higher threshold with active ischemic heart disease
  • Endoscopy within 24 hours after stabilization for most hospitalized UGIB
  • Suspected variceal bleeding: octreotide + ceftriaxone + urgent EGD with band ligation
  • Non-variceal bleeding ulcer after endoscopic hemostasis: high-dose PPI for 72 hours

Overview

Upper GI bleeding arises proximal to the ligament of Treitz. Causes include peptic ulcer disease, erosive esophagitis/gastritis, varices, Mallory-Weiss tear, malignancy, angioectasia, and Dieulafoy lesion. Management prioritizes hemodynamic stabilization before endoscopy and immediate variceal therapy when portal hypertension is suspected.

Epidemiology

UGIB is more common than lower GI bleeding. Risk factors include NSAID and antithrombotic exposure, cirrhosis, alcohol use disorder, advanced age, chronic kidney disease, and prior ulcer bleeding. Mortality is driven by comorbidity, shock, rebleeding, and variceal hemorrhage.

Clinical Features

Symptoms
Hematemesis or coffee-ground emesis
Melena
Hematochezia with shock can be brisk UGIB
Syncope, chest pain, dyspnea, or weakness from acute blood loss
Retching followed by hematemesis suggests Mallory-Weiss tear
Signs
Tachycardia, orthostatic hypotension, cool extremities, altered mental status
Epigastric tenderness with PUD or gastritis
Stigmata of cirrhosis: jaundice, ascites, spider angiomas, caput medusae
Rectal exam may show melena
Peritonitis suggests perforation or ischemia

Investigations

First-line
CBC, CMP, PT/INR, type and crossmatchAssess anemia, renal function, liver disease, coagulopathy, and prepare blood
BUN/creatinine ratioElevated ratio supports UGIB because digested blood increases urea absorption
Glasgow-Blatchford scoreIdentifies low-risk patients who may be managed outpatient
Second-line
Upper endoscopyDiagnostic and therapeutic; within 24 h after stabilization for most UGIB
Nasogastric lavageNot routine; may help if diagnosis uncertain but does not replace endoscopy
Specialist
CT angiographyIf ongoing bleeding and endoscopy is nondiagnostic or not possible
Interventional radiology angiographyEmbolization when endoscopic hemostasis fails

Management

ACG Upper Gastrointestinal and Ulcer Bleeding Guideline 2021
1
Immediate stabilization
  • Airway protection if massive hematemesis or aspiration risk
  • Two large-bore IVs, isotonic fluids, type and crossmatch
  • Hold/reverse anticoagulants for life-threatening bleeding when appropriate
  • Restrictive RBC transfusion threshold Hgb <7 g/dL in most patients
2
Non-variceal bleeding
  • IV PPI before endoscopy is reasonable but should not delay EGD
  • Endoscopic therapy for active bleeding, visible vessel, or adherent clot
  • After hemostasis: high-dose PPI for 72 h, then oral PPI
  • Rebleeding: repeat endoscopy, then transcatheter arterial embolization if failure
3
Suspected variceal bleeding
  • Start octreotide immediately
  • Start ceftriaxone for infection prophylaxis in cirrhosis
  • EGD within 12 h after stabilization with band ligation
  • Balloon tamponade/stent as bridge to TIPS if uncontrolled

Complications

  • Hemorrhagic shock: Tachycardia, hypotension, altered mental status.
  • Myocardial ischemia: Demand ischemia.
  • Rebleeding: Highest with visible vessel, large ulcer, shock, or varices.
  • Aspiration: Especially with massive hematemesis.
USMLE Step 2 CK Exam Tips
  • 1Melena usually means UGIB; hematochezia with shock can also be brisk UGIB
  • 2First step is stabilization, not endoscopy, in an unstable patient
  • 3Cirrhosis + hematemesis = octreotide + ceftriaxone + urgent band ligation
  • 4Transfusion threshold is Hgb <7 g/dL in most UGIB questions
  • 5Posterior duodenal ulcer can erode the gastroduodenal artery
  • 6Mallory-Weiss tear follows retching/vomiting and is usually self-limited
  • 7Do not forget H pylori testing after bleeding peptic ulcer

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regional clinical guidance

Upper GI Bleeding: guidance by region

Recommendations, thresholds and pathways can differ. Open the page written for the jurisdiction you need.

United StatesAcute upper gastrointestinal bleedingDigestive · reviewed 2026-08-20

Verified Sources & References

ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding 2021
AASLD Guidance: Ascites, SBP, and Hepatorenal Syndrome
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