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Nonvariceal upper GI bleeding — ABIM Board MCQ

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HardGastroenterology/HepatologyNonvariceal upper GI bleedingABIM Board

A 64-year-old man who takes naproxen daily presents with melena and presyncope. His initial blood pressure is 84/52 mm Hg and pulse is 118/min. Hemoglobin is 7.4 g/dL, blood urea nitrogen is 48 mg/dL, creatinine is 1.0 mg/dL, platelet count is 210,000/mm3, and INR is 1.1. He has no history or examination findings of cirrhosis. After intravenous crystalloid and packed red blood cell transfusion, his blood pressure is 112/68 mm Hg, pulse is 92/min, and mental status and urine output are normal. Intravenous proton pump inhibitor therapy is started. His Glasgow-Blatchford score is 13. Which of the following is the most appropriate next management step?

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Correct answer: A — Upper endoscopy after resuscitation and within 24 hours of presentation

The correct answer is A. This patient has high-risk, likely NSAID-associated nonvariceal upper gastrointestinal bleeding but has responded to initial hemodynamic resuscitation. Hospitalized patients should undergo upper endoscopy within 24 hours of presentation; endoscopy both identifies the source and permits hemostatic treatment. Even in stabilized patients with a Glasgow-Blatchford score of at least 12, endoscopy within 6 hours has not improved mortality compared with endoscopy during the subsequent 6–24 hours. CT angiography and transcatheter embolization are generally reserved for ongoing bleeding when endoscopy is unsuccessful or cannot be performed. Tagged red blood cell scintigraphy provides no therapeutic capability and is poorly suited to this clear upper gastrointestinal presentation. Colonoscopy is considered if upper endoscopy is negative, and surgery is reserved for bleeding uncontrolled by endoscopic and interventional radiologic therapy.

Reference: Yadlapati R, et al. Updated Quality Indicators for Upper GI Endoscopy, ACG/ASGE, 2025. https://learn.asge.org/AssetListing/Updated-Quality-Indicators-for-Upper-GI-Endoscopy-April-2025-4237/Recorded-Webinar-34675