{"id":3538,"date":"2021-06-23T12:50:00","date_gmt":"2021-06-23T12:50:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=3538"},"modified":"2025-10-17T15:45:02","modified_gmt":"2025-10-17T23:45:02","slug":"usmle-step-2-question-of-the-day-causes-of-upper-gastrointestinal-bleeds","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-causes-of-upper-gastrointestinal-bleeds","title":{"rendered":"USMLE\u00ae Step 2 Question of the Day: Causes of Upper Gastrointestinal Bleeds"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-causes-of-upper-gastrointestinal-bleeds\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-causes-of-upper-gastrointestinal-bleeds\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-causes-of-upper-gastrointestinal-bleeds\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-causes-of-upper-gastrointestinal-bleeds\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-causes-of-upper-gastrointestinal-bleeds\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><em>We&#8217;re back with a <strong>USMLE\u00ae Step 2 CK <\/strong>Question of the Day!\u00a0<em>Today&#8217;s case involves a <strong>48-year-old man vomiting blood.<\/strong> Can you determine the best next step in the management of this patient?<\/em><\/em> <em>Let&#8217;s find out!<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A <strong>48-year-old male<\/strong> is brought to the <strong>emergency room<\/strong> after <strong>vomiting bright red blood<\/strong>. The patient was at home <strong>eating almonds<\/strong> when he suddenly felt nauseous and vomited. He denies any recent trauma. Past <strong>medical history<\/strong> is notable for<strong> alcohol use disorder<\/strong>. His temperature is <strong>37.5\u00b0C (99.5\u00b0F), blood pressure is 95\/68 mmHg, and pulse is 105\/min.<\/strong> Examination of the eyes reveals <strong>scleral icterus<\/strong>. Abdominal exam reveals <strong>hepatomegaly <\/strong>and <strong>distended veins<\/strong> radiating from the <strong>umbilicus<\/strong>. While in the emergency department, the patient has a <strong>second episode of bloody vomiting<\/strong>. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Which of the following is the <em>next best step<\/em> in the management of this patient?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Perform upper gastrointestinal endoscopy<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Administration of propranolol<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Perform fecal occult blood test<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Placement of intravenous catheters<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Initiation of octreotide therapy<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-rich is-provider-embed-handler wp-block-embed-embed-handler wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Osmosis.org at the University of Maryland\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/Zq98kc0sXBs?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Placement of intravenous catheters<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the&nbsp;<strong>Main Explanation<\/strong>, let&#8217;s see why the answer wasn&#8217;t A, B, C, or E. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Perform upper gastrointestinal endoscopy<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>\u00a0An <strong>upper gastrointestinal endoscopy<\/strong> can be used to <strong>diagnose <\/strong>and treat <strong>variceal bleeding<\/strong>. However, this patient is <strong>tachycardic <\/strong>and <strong>borderline hypotensive<\/strong>. The patient should first be stabilized, which can be achieved by placing <strong>peripheral IVs <\/strong>and <strong>initiating fluid resuscitation<\/strong>. Only afterwards should endoscopy be performed.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Administration of propranolol<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect: <a href=\"https:\/\/www.osmosis.org\/learn\/Class_II_antiarrhythmics:_Beta_blockers\" target=\"_blank\" rel=\"noreferrer noopener\">Propranolol<\/a>\u00a0<\/strong>can be used for <strong>bleeding prophylaxis<\/strong> in patients with esophageal varices. However, this patient has <strong>active bleeding<\/strong>, as suggested by the bright red emesis, <strong>tachycardia<\/strong>, and <strong>borderline-hypotension<\/strong>. Propranolol is ineffective in stopping active variceal bleeding.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Perform fecal occult blood test<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>\u00a0This patient has\u00a0<strong><a href=\"https:\/\/www.osmosis.org\/learn\/Gastrointestinal_system_anatomy_and_physiology\" target=\"_blank\" rel=\"noreferrer noopener\">gastrointestinal tract<\/a>\u00a0bleeding<\/strong> and will have a <strong>positive fecal occult blood test<\/strong>. However, it is important to first <strong>stabilize the patient<\/strong> before performing any diagnostic testing.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Initiation of octreotide therapy<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Octreotide can be used to stop acute variceal bleeding and should be continued for 3-5 days. However, this patient is tachycardic and borderline hypotensive. The patient should first be stabilized by placing peripheral IVs and initiating fluid resuscitation. Afterwards, octreotide can be administered.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient has <strong>hematemesis <\/strong>in the setting\u00a0<a href=\"https:\/\/www.osmosis.org\/learn\/Cirrhosis\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>liver cirrhosis<\/strong><\/a>\u00a0and subsequent\u00a0<a href=\"https:\/\/www.osmosis.org\/learn\/Portal_hypertension\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>portal hypertension<\/strong><\/a>, which is most consistent with a\u00a0<strong>variceal bleed<\/strong>. Other cases of upper gastrointestinal (GI) bleeding include\u00a0<strong><a href=\"https:\/\/www.osmosis.org\/learn\/Peptic_ulcer\" target=\"_blank\" rel=\"noreferrer noopener\">peptic ulcers<\/a><\/strong>,\u00a0<strong>Mallory-Weiss tears<\/strong>,\u00a0<strong>esophageal perforation<\/strong>, and\u00a0<strong>vascular malformations<\/strong>\u00a0(e.g. <strong>Dieulafoy lesions<\/strong>). Patients can present with hematemesis (vomiting of fresh red blood), <strong>\u2018coffee ground\u2019 vomitus<\/strong> (vomiting of blood that has been oxidized by stomach acids), and <strong>melena <\/strong>(black and tarry stools).<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Since <strong>upper GI bleeding<\/strong> is potentially <strong>life-threatening<\/strong>, with a mortality rate of 2-10%, aggressive management is warranted. The first step is to place at least\u00a0<strong>two large-bore intravenous catheters<\/strong>. Afterwards, patients should be started on\u00a0<strong>intravenous fluids<\/strong>\u00a0and <strong>empiric intravenous<\/strong>\u00a0<strong><a href=\"https:\/\/www.osmosis.org\/learn\/Acid_reducing_medications\" target=\"_blank\" rel=\"noreferrer noopener\">proton pump inhibitors<\/a><\/strong>\u00a0to reduce gastric acid production and enable <strong>clot formation<\/strong>. If the patient\u2019s hemoglobin is low (hemoglobin &lt; 7 g\/dL), a <strong>blood transfusion<\/strong> may be required. Patients are allowed to consume\u00a0<strong>nothing by mouth<\/strong>\u00a0(NPO).<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Once the cause of bleeding has been determined (e.g., via endoscopy, imaging, etc.), patients can be started on medications more specific to the underlying condition.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">There are many causes of upper gastrointestinal bleeding. The first step in management is to place&nbsp;<strong>two large-bore intravenous catheters<\/strong>. Afterwards, patients should be started on&nbsp;<strong>intravenous fluids<\/strong>&nbsp;and&nbsp;<strong><a href=\"https:\/\/www.osmosis.org\/learn\/Acid_reducing_medications\" target=\"_blank\" rel=\"noreferrer noopener\">proton pump inhibitors<\/a><\/strong>. Patients should also be made&nbsp;<strong>NPO<\/strong>.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Antunes, C., Copelin II, E.L. (2019) \u201cUpper gastrointestinal bleeding\u201d.&nbsp;<em>StatPearls[Internet]<\/em>. Web Address:&nbsp;<a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK470300\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK470300\/<\/a>.<\/li>\n\n\n\n<li>Stanley, A.J., Laine, L. (2019) Management of acute upper gastrointestinal bleeding.\u00a0<em>The BMJ<\/em>. 364, I536.\u00a0<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/30910853\/\" target=\"_blank\" rel=\"noreferrer noopener\">Doi: 10.1136\/bmj.l536.<\/a><\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?w=700\" alt=\"\" class=\"wp-image-5904\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Want more <strong>USMLE\u00ae Step 2 CK <\/strong>practice questions?\u00a0Try <strong>Osmosis from Elsevier<\/strong> today! Access your\u00a0<a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>free trial<\/strong><\/a>\u00a0and find out why millions of current and future clinicians and caregivers love learning with us.<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A middle-aged man with cirrhosis and vomiting blood requires urgent care. Discover what the critical first step you need to take in his medical care.<\/p>\n","protected":false},"author":202,"featured_media":3539,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,1366,1370,45],"tags":[2027,1344,440,2026,2024,2025,2019,2023,2022,2020,1594,2021,2018,952,2017],"class_list":["post-3538","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-questions","category-step-2-questions","category-step-2","tag-acute-bleeding","tag-critical-care","tag-emergency-medicine","tag-esophageal-varices","tag-fluid-resuscitation","tag-gi-bleed-management","tag-hematemesis","tag-iv-catheter","tag-liver-cirrhosis","tag-octreotide","tag-portal-hypertension","tag-proton-pump-inhibitors","tag-upper-gi-bleed","tag-usmle-step-2-ck","tag-variceal-bleeding"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 Question of the Day: Causes of Upper Gastrointestinal Bleeds - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-causes-of-upper-gastrointestinal-bleeds\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 Question of the Day: Causes of Upper Gastrointestinal Bleeds - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"A middle-aged man with cirrhosis and vomiting blood requires urgent care. 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Test your clinical assessment skills and prepare effectively for your exam!","rel":"","context":"In &quot;Allopathic Medicine (MD)&quot;","block_context":{"text":"Allopathic Medicine (MD)","link":"https:\/\/www.osmosis.org\/blog\/category\/medicine"},"img":{"alt_text":"Step 2 CK Question of the Day Left back pain","src":"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/04\/Step2_QOTD_Q1_Leftbackpain_2025_SM.png","width":350,"height":200,"srcset":"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/04\/Step2_QOTD_Q1_Leftbackpain_2025_SM.png 1x, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/04\/Step2_QOTD_Q1_Leftbackpain_2025_SM.png 1.5x, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/04\/Step2_QOTD_Q1_Leftbackpain_2025_SM.png 2x"},"classes":[]},{"id":3763,"url":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-pelvic-pain","url_meta":{"origin":3538,"position":4},"title":"USMLE\u00ae Step 2 Question of the Day: Pelvic pain","author":"Marina Horiates Kerekes, MD &amp; Team","date":"May 29, 2024","format":false,"excerpt":"Learn about a USMLE Step 2 question involving a 28-year-old woman with a ruptured ectopic pregnancy, presenting with severe pelvic pain, hypotension, and a positive hCG. Understand the significance of emergent laparoscopy to control bleeding and remove damaged tissue.A 28-year-old woman comes to the emergency department for evaluation of right-sided\u2026","rel":"","context":"In &quot;Allopathic Medicine (MD)&quot;","block_context":{"text":"Allopathic Medicine (MD)","link":"https:\/\/www.osmosis.org\/blog\/category\/medicine"},"img":{"alt_text":"USMLE\u00ae Step 2 Question of the Day: Pelvic pain","src":"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-19T130157.707.webp","width":350,"height":200,"srcset":"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-19T130157.707.webp 1x, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-19T130157.707.webp 1.5x, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-19T130157.707.webp 2x"},"classes":[]},{"id":2055,"url":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-thyroid-storm","url_meta":{"origin":3538,"position":5},"title":"USMLE\u00ae Step 2 CK Question of the Day: Thyroid Storm","author":"Marina Horiates Kerekes, MD &amp; Team","date":"January 1, 2022","format":false,"excerpt":"Here's another USMLE\u00ae Step 2 CK Question of the Day!\u00a0Today's case involves a 45-year-old woman with altered mental status, nausea, vomiting, and diarrhea. 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