Tests
1st tests to order
CBC
Test
Should be part of the initial evaluation in any patient who presents with hemorrhage.
Patients with ongoing blood loss (hematemesis, hematochezia, or melena) or suspected of having cardiac ischemia should be considered for packed red blood cells (PRBC) transfusion. Guidelines differ in exact hemoglobin thresholds for transfusion.[39][40][41]
Result
Hb, hematocrit, and platelets are usually unremarkable in the acute setting; however, anemia may range from mild to severe in rare cases
BUN
Test
Should be part of the initial evaluation in any patient who presents with hemorrhages.
BUN/Cr is an important parameter to evaluate the severity of bleeding and to monitor the patient. BUN level at initial presentation is considered a weak predictor of the severity of upper gastrointestinal bleeding.[55]
Result
high in patient with ongoing bleeding
creatinine and electrolytes
Test
Important to evaluate the severity of the bleeding, make a risk assessment, and monitor patients.
Result
may be abnormal in a patient with shock
LFT
Test
Should be part of the initial blood work in patients with hemorrhages.
Used to rule out liver disease, which may predispose a patient to esophageal varices, gastric varices, or portal hypertensive gastropathy as potential sources of bleeding.
Result
typically normal, except in a patient with underlying or coexisting liver disease
prothrombin time (PT)/INR
Test
Prolonged PT times may be a result of anticoagulation therapy, liver pathology, lupus, and other coagulopathies.
Result
typically normal
PTT
Test
Prolonged PTT times may be a result of anticoagulation therapy, liver pathology, lupus, and other coagulopathies.
Result
typically normal
crossmatching/blood grouping
Test
Should be part of the initial blood work in any patient with hemorrhages. Candidates for blood transfusion include those with anemia at presentation or ongoing bleeding.
Result
variable
flexible esophagogastroduodenoscopy (EGD)
Test
The diagnostic test of choice and should be performed in patients with upper gastrointestinal bleeding after stabilization and once patients are deemed acceptable candidates for the procedure.[45][49][56] Patients with a Glasgow-Blatchford score (GBS) ≥2 should be admitted promptly and receive an endoscopy within 24 hours.[1][39] Patients with a GBS 0-1 may have their endoscopy as outpatients. [ Blatchford score for gastrointestinal bleeding Opens in new window ]
From the personal collection of Douglas Adler; used with permission
Result
tear or laceration typically appears as a single red longitudinal defect with normal surrounding mucosa; the lesions vary from a few millimeters to several centimeters; tear usually seen at or below the gastroesophageal junction on the lesser curvature (between 2 and 6 o'clock); rarely, there may be more than one tear; coexisting lesions are common (e.g., peptic ulcer, erosive esophagitis)
Tests to consider
CT chest
Test
Indicated to confirm a suspected perforation (patients presenting with subcutaneous emphysema or crepitus) and localize the level.[46]
Result
may reveal extraluminal air and a site of perforation, if present
CXR
Test
Laceration or tear is not visible under conventional radiography; may be an initial test diagnosis in patients with suspected esophageal perforation.
A contrast study is indicated to confirm and localize the level of esophageal perforation.[46]
Result
typically normal in uncomplicated Mallory-Weiss tear
angiography
Test
Either visceral angiography, or CT angiography of the abdomen and pelvis without and with intravenous contrast, is indicated in patients where there is an actively bleeding lesion and endoscopy is unavailable, or EGD evaluation is contraindicated or has failed to control the bleeding.[45][47] Where endoscopy confirms nonvariceal upper gastrointestinal bleeding but cannot clearly identify the bleeding site, CT angiography of the abdomen and pelvis without and with intravenous contrast is indicated.[45]
Result
selective cannulation of the mesenteric or left gastric artery may reveal a bleeding point in ≤75% of patients in which endoscopy has failed to control the bleeding; linear collection of contrast will be seen in patients with tear or laceration at or near to the gastroesophageal junction
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