A 45-year-old man presents with hematemesis and melena; he has NSAID use and alcohol; an NG tube yields bright red blood that does not clear with saline. What is the next best step in management?

A 45-year-old man presents with hematemesis and melena; he has NSAID use and alcohol; an NG tube yields bright red blood that does not clear with saline. What is the next best step in management?

• A. Transfuse 2 units of packed red blood cells
• B. Administer IV fluids and observation
• C. Refer for emergency endoscopy
• D. Obtain an abdominal CT scan

Answer: (C)

Persistent bright red blood through the NG tube means the bleed is ongoing and active from the upper GI tract. In this situation, the priority is to locate and stop the source as quickly as possible, which is achieved with endoscopy. Endoscopy is both diagnostic and therapeutic: it lets you see the ulcer or lesion causing the bleed and apply hemostatic measures (such as clipping, injection, or cautery) right away. CT imaging won’t identify or control an active mucosal bleed, and simply giving fluids or observing won’t address the source. While resuscitation and blood products may be needed, the best next step to manage this active upper GI bleed is urgent endoscopy for localization and hemostasis.

Persistent bright red blood through the NG tube means the bleed is ongoing and active from the upper GI tract. In this situation, the priority is to locate and stop the source as quickly as possible, which is achieved with endoscopy. Endoscopy is both diagnostic and therapeutic: it lets you see the ulcer or lesion causing the bleed and apply hemostatic measures (such as clipping, injection, or cautery) right away. CT imaging won’t identify or control an active mucosal bleed, and simply giving fluids or observing won’t address the source. While resuscitation and blood products may be needed, the best next step to manage this active upper GI bleed is urgent endoscopy for localization and hemostasis.