The Invisible Bleed - The Emergency Medical Minute

the invisible bleed

Chief Complaint:



43-year-old woman with a history of gastroparesis and seizures suddenly vomited blood about 4 hours prior to arrival to the ED. She has never vomited blood like this before. She describes copious hematemesis with clots. She has a history of esophagitis with mild hematemesis several years in the past. She denies any history of liver disease or varices. She has been taking ibuprofen 600 mg 1-3 times a day recently over the last week. She also complains of black stool, abdominal pain, fatigue, and 4-5 syncopal episodes today.

Pertinent Exam Findings:

Vital Signs: BP 85/58, HR 109
Constitutional: Patient is awake, alert and acutely ill-appearing as well as pale.
Eyes: Subconjunctival pallor, pupils equal, eye movements normal.
HENT: Dry mucus membranes
Respiratory: No respiratory distress, no accessory muscle use, speaking in full sentences.
Cardiovascular: Tachycardic, regular rhythm, delayed cap refill
Gastrointestinal: Abdomen soft, + epigastric abdominal tenderness, no stigmata of cirrhosis
Skin: Pale, dry, no rash

Data Interpretation:

CBC: Hg 4.9 Hct 19.0 (chart review showed a prior Hg as recent as 1 year prior that was normal)
EtOH: 186
LFTs, Lipase, BMP, Trop, INR all not clinically significant

ED Course:

Patient received IV PPI, transfused 2 units PRBC, 1L NS while waiting for PRBC.

Patient vomited about 150cc dark red blood while in the ED.

GI was consulted for emergent endoscopy.

Admitted to ICU where GI plans to do EGD.

Hospital Course:

On arrival to the ICU, endoscopy was performed. Patient had esophagitis without bleeding and stomach was found to have moderate gastritis. There was no evidence of Mallory-Weiss tear, duodenal ulcers or varices.

The patient corrected only to a Hg of 6.7 from 4.9 after 2 units of PRBCs in the ED. She received an additional 1 unit of PRBCs in the ICU on day 2. On day 3 she was placed on the medical floor. At that time she was diagnosed with acute on chronic pancreatitis based on abdominal CT scan. On day 4 she had an episode of non-bloody emesis thought to be related to her gastroparesis. Although not visualized on the endoscopy, GI attributed the source of the patient’s bleeding to a Dieulafoy’s lesion, a diagnosis of exclusion in these circumstances. Her hospital stay was prolonged due to social complications and she was discharged on hospital day 8.



Dieulafoy’s lesion is an uncommon cause of severe and sudden gastrointestinal bleeding that occurs when a dilated submucosal vessel erodes through the enteric epithelium. It typically occurs in the stomach along the lesser curvature, but cases have been reported in all areas of the GI tract. Dieulafoy’s lesion accounts for about 1.5% of acute gastrointestinal bleeding and presents a difficult diagnostic challenge due to its small size and irregular bleeding pattern. There is no known etiology, but demographic risk factors for the development of these lesions are frequently in men with cardiovascular disease, chronic kidney disease, alcohol abuse, diabetes, and hypertension. There is a possible association with chronic NSAID use and development of bleeding, but the association is poorly understood. While many bleeding episodes are self-resolving, if left undiagnosed and untreated, some can lead to massive hemorrhage and ultimately death.


The diagnosis of Dieulafoy’s lesion is typically considered only after ruling out more common causes of upper GI bleeds such as peptic ulcer disease, esophageal varices, Mallory-Weiss tears, and mimics of upper GI bleeds such as hemoptysis or ENT bleeds. Approximately 10% of patients with upper gastrointestinal bleeding have no clear source of bleeding and in these patients Dieulafoy’s lesion should be considered. Diagnosis is determined through physical exam findings, history of present illness, and diagnostic imaging. Patients will frequently present with hematemesis, melena, or hematochezia, but occasionally patients may only present with abnormal blood pressures. Lab findings may include a blood urea nitrogen to creatinine ratio of greater than 30 and anemia secondary to blood loss. Endoscopy is the gold standard for diagnosis of Dieulafoy’s lesion, especially when a patient is experiencing a bleeding episode. Endoscopic ultrasound can be used to confirm endoscopy findings, as well. Initial endoscopy will correctly identify patients 70% of the time, but several endoscopies may be required to establish a diagnosis as the lesions are frequently overlooked if not actively bleeding due to their small size.

Management in ED:

For hemodynamically unstable patients, the ABCs should be done first and foremost. Regarding management of the airway, there is evidence that prophylactically intubating critically ill patients with GI bleeding had worse outcomes than those who were not prophylactically intubated. Establishing two large bore IVs and beginning fluid and blood product resuscitation should be done alongside the assessment of airway. Along with this, an IV PPI (such as omeprazole) should be given prior to transfer to the ICU with a GI consult for continuing care. Interventional radiology or surgery may require a consult in cases of severe upper GI bleeding. If the patient is thrombocytopenic, a platelet transfusion may be indicated. If the patient is coagulopathic, FFP can be given. Octreotide is not indicated in non-variceal bleeding.

For hemodynamically stable patients, patient’s may be placed on oxygen via nasal cannula and be kept NPO. Two large bore IVs should be placed and IV fluids should be administered in the absence of contraindications to fluid resuscitation. These patients may need a blood transfusion in the future, so sending a type and match is necessary. Again, an IV PPI should be given with active GI bleeding. In all cases, GI should be consulted to assist in the management of the patient. Most patients will require admission to a medical floor for further monitoring, endoscopy, and consideration for operative management.


There are three different calculators to determine risk of mortality from an acute upper GI bleed, the Glasgow-Blatchford score (GBS), Rockall score, and the AIMS65 score. The GBS takes into account lab findings, vitals, comorbidities, and presenting symptoms to determine if the bleed is high risk and to inform the course of care. The Rockall score uses age, blood pressure, comorbidities, and endoscopic findings/diagnosis to estimate rebleeding risk and mortality risk. Lastly, the AIMS65 score uses mental status, age, blood pressure, albumin level, and INR to estimate in-hospital mortality in patients with an upper GI bleed.

While a large part of the prognosis for a patient with Dieulafoy’s lesion is dependent on the quantity of the bleeding, only 10% of patients with this diagnosis have life-threatening bleeding. After stabilization and definitive treatment of the lesion, either endoscopically or surgically, the re-bleeding risk is between 9-40% and the mortality is estimated to be 8.9%. This is a large decrease from the previous mortality of 80%, which has been reduced mostly due to endoscopic advancements in diagnosis and treatment. Currently the outcomes with Dieulafoy’s lesion are more favorable than those of peptic or duodenal ulcers.

Differential Diagnoses:

    • Esophageal or gastric varices
    • Gastric ulcer
    • Mallory-Weiss tear
    • Malignant neoplasm
    • Dieulafoy lesion
    • Aortoenteric fistula
    • Benign gastric tumors
    • Disseminated intravascular coagulation
    • Zollinger-Ellison syndrome

Clinical Pearls:

    • ABC’s first, although don’t prophylactically intubate.
    • Fluid resuscitation and transfusion of blood products are key, especially if patient is hemodynamically unstable.
    • Treat with IV proton pump inhibitor.
    • Get GI on board early for endoscopic diagnosis and treatment.
    • Patient prognosis can be determined using the Glasgow-Blatchford score (GBS), Rockall score, and/or the AIMS65 score.


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Aaron Wolfe, DO, FACEP

John Spartz, MSIV

Peter Haskins, MSIV


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