IM15.{4-5,7-8} | GI Bleeding Clinical Evaluation — Summary & Reflection

KEY TAKEAWAYS

Clinical evaluation of GI bleeding integrates three simultaneous objectives: localisation, severity assessment, and risk stratification. The structured history covers: route/character (haematemesis = upper; haematochezia = lower in most cases), quantity/haemodynamic symptoms (syncope/presyncope = ≥1 litre loss), duration and pattern, associated symptoms (pain character, weight loss, bowel habit change), aetiological risk factors (NSAIDs, alcohol, liver disease, prior surgery), and comorbidities.

Physical examination priorities: vital signs and postural BP (drop ≥20 mmHg systolic = significant volume loss), stigmata of chronic liver disease (spider naevi, palmar erythema, ascites, splenomegaly = variceal risk), and abdominal examination (tenderness, masses, bowel sounds).

DRE: inspect first (haemorrhoids, fissure, fistula), then digital palpation (prostate/posterior vaginal wall, rectal walls for mass, sphincter tone, stool character and colour on withdrawal). Firm irregular mass = carcinoma until proved otherwise — urgent endoscopy.

Differential prioritisation: match aetiological probability to clinical pattern (NSAID+epigastric pain=PUD; stigmata+UGIB=varices; elderly painless haematochezia=diverticular; young bloody diarrhoea+systemic=IBD); apply must-not-miss principle (aortoenteric fistula in prior graft; CRC in over-45 with rectal bleeding). Glasgow-Blatchford Score ≥6 = high-risk UGIB requiring urgent intervention.

REFLECT

Return to the opening hook — two patients with GI bleeding presenting the same afternoon, one needing reassurance and the other needing urgent intervention. Having worked through this module, what are the specific history and examination findings that would place each patient in their correct risk category within three minutes of your first encounter? Think about a clinical scenario where a patient insists their rectal bleeding is 'just piles like before' — how would you decide whether their reassurance is well-founded or whether further investigation is mandatory, and how would you communicate the need for colonoscopy to a patient who is convinced it is unnecessary? These moments of clinical advocacy — where the examination contradicts the patient's narrative — are among the most important skills this module prepares you to navigate.