CCFP priority topic 42 of 105
Gastro-intestinal Bleed on the CCFP exam
6 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 6 key features for Gastro-intestinal Bleed. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 6
Upper or lower
Steady vital signs and bloody or black stool: let the history say upper or lower.
CFPC skill Clinical reasoningPhase Diagnosis, historySources Canadian Association of Gastroenterology
On the exam
A 12-year-old has two days of black stool and no diarrhea. Expect a short menu (pick several from a list) of questions to ask.
Pick the questions that place the source.
Common mistakes
Chasing a fissure, an infection or Crohn disease. Those give red streaks or loose stool, not black stool. Ultrasound cannot see a bleeding ulcer, and a CT scan seldom does.
Approach
- Black, tarry, sticky stool (melena) is digested blood. Most often it comes from the stomach or duodenum.
- Ask about vomiting blood or coffee-ground material, ulcer pain, anti-inflammatories (NSAIDs), acetylsalicylic acid (ASA), alcohol and liver disease.
- Bright red blood on or in the stool usually comes from the colon, rectum or anus. Ask about a change in bowel habit, weight loss and anal pain.
- Red or maroon stool with a fast pulse can still be a brisk upper bleed.
- An upper source needs upper endoscopy: it finds the bleeding point and treats it. The 2019 guideline suggests it within 24 hours for patients admitted with an acute upper bleed.
- A lower source needs a look from below: the anus and rectum first, then colonoscopy.
| Clue | Points upper | Points lower |
|---|---|---|
| Stool | Black, tarry, sticky | Bright red, streaked on or mixed in |
| Vomit | Blood or coffee-ground material | None |
| Other history | Ulcer pain, NSAIDs, ASA, alcohol, liver disease | Change in bowel habit, weight loss, anal pain |
| First scope | Upper endoscopy | Look at the anus and rectum, then colonoscopy |
Key feature 2 of 6
Not blood at all
Before a big work-up for possible stool blood, rule out foods and drugs that mimic it.
CFPC skill Clinical reasoningPhase Hypothesis generation, historySources Choosing Wisely Canada
On the exam
Dark stool in a well patient who started a new pill last week. Expect one best answer for the first step.
Pick the first question to ask.
Common mistakes
Booking a scope before asking what the patient ate or took. The reverse costs marks too: blaming iron for tarry stool in a patient who feels faint.
Approach
- Ask about beets, red food dye and red drinks. They can turn stool red.
- Ask about iron pills and bismuth subsalicylate (Pepto-Bismol). Both can turn stool black.
- Look at the stool itself. Melena is tarry, sticky and smells foul. Stool darkened by iron or bismuth is usually formed and not sticky.
- Ask where else blood could come from: a nosebleed, bleeding gums, a period or blood in the urine. A breastfed baby can swallow blood from a cracked nipple.
- If the story is unclear, check the pulse, blood pressure lying and standing, and a hemoglobin.
- Do not use a guaiac stool test to sort it out. It is not accurate enough to decide on a scope.
Key feature 3 of 6
Who is at risk
Spot patients likely to bleed from the gut, and change their care to lower that risk.
CFPC skill Clinical reasoningPhase Hypothesis generation, historySources Canadian Association of Gastroenterology, Choosing Wisely Canada
On the exam
A teen has black stool after 12 days of ibuprofen for a sprain. Expect one best answer for pain relief from now on.
Pick the safest plan for pain from now on.
Common mistakes
Giving the NSAID with food or at half the dose. Food eases heartburn but does not prevent ulcers. A lower dose still carries risk after a bleed.
Approach
- Ask about a past ulcer or gastro-intestinal (GI) bleed, NSAIDs, ASA, blood thinners, steroids taken with an NSAID, heavy alcohol use and critical illness in intensive care.
- After an ulcer bleed, avoid NSAIDs where you can. An NSAID plus a proton pump inhibitor (PPI), or a COX-2 inhibitor such as celecoxib alone, still carries real rebleeding risk.
- If an NSAID is truly needed after an ulcer bleed, use a COX-2 inhibitor plus a PPI.
- Past ulcer bleed and taking ASA, another antiplatelet or an anticoagulant for the heart or for clots: add a PPI.
- After an ulcer bleed, test for Helicobacter pylori. Treat it and confirm it is gone. Repeat a negative test taken during the bleed.
- Do not switch a child to ASA. It is an NSAID too, and risks Reye syndrome with a viral illness.
- A past GI bleed is an exception to the yearly trial off a long-term PPI.
Key feature 4 of 6
Danger before shock
Pick out the bleeding patient who needs fast care before the blood pressure falls.
CFPC skill Clinical reasoning, selectivityPhase Hypothesis generation, diagnosisSources Canadian Association of Gastroenterology
On the exam
A child with melena has a pulse of 128, slow capillary refill and a normal pressure. Expect a short menu (pick several from a list) of findings that matter.
Pick the signs of blood loss now.
Common mistakes
Blaming a fast pulse on fear, or feeling safe with a normal pressure. Children and fit young adults keep their pressure until late in a bleed.
Approach
- Look for loss now: a fast pulse at rest, dizziness or fainting on standing, slow capillary refill (colour slow to return after pressing a nail), cold hands, new confusion.
- More melena overnight, fresh blood, or a falling hemoglobin means the bleed has not stopped.
- The first hemoglobin can look normal. After sudden loss it takes time to fall.
- Score adults with the Glasgow-Blatchford score, built from blood tests and vital signs. At 1 or less, risk is very low; the patient may not need admission or inpatient endoscopy.
- In a stable adult with an upper bleed and no heart disease, transfuse below hemoglobin 80 g/L. Heart disease calls for a higher threshold. Massive bleeding is different.
- Blood thinners do not delay endoscopy. See the table for what the 2022 joint guideline suggests.
| Drug | What to do | What to avoid |
|---|---|---|
| Warfarin | If reversal is needed: prothrombin complex concentrate (PCC) | Fresh frozen plasma; vitamin K |
| Direct oral anticoagulant (apixaban, rivaroxaban, dabigatran) | Endoscopy without delay | PCC; idarucizumab; andexanet alfa |
| ASA or another antiplatelet | Keep ASA taken for heart disease. If stopped, restart the day endoscopy shows the bleeding is controlled. | Platelet transfusion; holding ASA taken for heart disease |
Key feature 5 of 6
Look past the obvious
Rectal bleeding with steady vital signs: search for a serious cause, even beside a clear one.
CFPC skill Clinical reasoning, selectivityPhase Hypothesis generationSources Choosing Wisely Canada, Canadian Association of Gastroenterology
On the exam
A 64-year-old on warfarin has bright red blood and visible hemorrhoids. Expect one best answer for the next step.
Pick the next step.
Common mistakes
Treating the hemorrhoids, or adjusting the warfarin, and stopping there. A blood thinner makes a lesion bleed; the lesion still needs finding.
Approach
- Ask about a change in bowel habit, weight loss, tiredness, belly pain, diarrhea at night, and family history of colorectal cancer or inflammatory bowel disease.
- Rectal bleeding, weight loss and anemia are alarm features. They call for a look with colonoscopy.
- Blood thinners raise bleeding from lesions already there, such as ulcers or diverticula. Bleeding on one is a reason to look, not a cause.
- Check the hemoglobin and iron stores. Low iron points to slow loss over time.
- Do not send a guaiac stool test or a fecal immunochemical test (FIT) for visible bleeding. FIT is for screening people with no symptoms.
- Red blood with a fast pulse may still come from above: think of an ulcer or varices.
Key feature 6 of 6
Varices
When blood comes up, ask if it could be varices, and look for the clues.
CFPC skill Clinical reasoningPhase Hypothesis generation, history, physicalSources Canadian Association of Gastroenterology
On the exam
A 17-year-old vomits bright red blood after hours of retching. Expect a short menu (pick several from a list) of questions and exam findings.
Pick what to ask and look for.
Common mistakes
Calling it varices because an uncle died of liver disease, or calling it an ulcer by habit. With no liver signs, blood after hard retching points to a tear.
Approach
- Think of varices in every upper bleed. They come from high pressure in the portal vein, most often from cirrhosis.
- Ask about known liver disease, heavy alcohol use, hepatitis B or C, and a past variceal bleed. In a child, ask about an umbilical line as a newborn.
- Examine for jaundice, spider nevi, red palms, a big spleen, fluid in the belly (ascites) and confusion.
- Clear vomit, then blood after hard retching, fits a tear where the esophagus meets the stomach (Mallory-Weiss tear). Most stop on their own.
- If varices are likely, say so early. Their treatment differs from ulcer care, and the 2019 upper bleed guideline does not cover them.
| Clue | Varices | Mallory-Weiss tear |
|---|---|---|
| History | Cirrhosis, heavy alcohol use, hepatitis B or C, past variceal bleed | Retching or vomiting before the blood |
| Exam | Jaundice, spider nevi, ascites, big spleen | Often normal |
| Blood | Often a large volume of red blood | Clear vomit first, then blood |
| Next step | Tell the team early: their care differs | Watch: more melena or a falling hemoglobin means it has not stopped |
Flashcards
Answer it first, then check.
KF 1A stable 12-year-old has black, sticky stool and no diarrhea. Where is the bleed?
Most likely the stomach or duodenum. Melena is digested blood, so upper endoscopy comes first.
KF 2A patient on iron has dark, formed stool and feels well. What do you check first?
The history and the stool itself. Iron darkens stool; melena is tarry, sticky and smells foul.
KF 3After an ulcer bleed, a patient needs an NSAID for arthritis. What is the safest plan?
A COX-2 inhibitor plus a PPI. Either one alone still carries real rebleeding risk. Source: Canadian Association of Gastroenterology
KF 4An adult with melena has a Glasgow-Blatchford score of 1. Must the patient be admitted?
Not always. A score of 1 or less means very low risk; care outside hospital may be fine. Source: Canadian Association of Gastroenterology
KF 4Stable upper bleed, no heart disease, hemoglobin 92 g/L. Do you transfuse?
No. Without heart disease, the threshold is below 80 g/L. Blood does not find the source. Source: Canadian Association of Gastroenterology
KF 4Melena in a patient on warfarin. Do you give plasma or vitamin K?
The 2022 joint guideline suggests against both. If reversal is needed, it suggests PCC. Do not delay endoscopy. Source: Canadian Association of Gastroenterology
KF 5Bright red blood, hemorrhoids seen, and the patient takes warfarin. Are you done?
No. Rectal bleeding is an alarm feature. Look higher with colonoscopy; warfarin is a reason to look, not a cause. Source: Choosing Wisely Canada, Canadian Association of Gastroenterology
KF 6Blood in the vomit, with ascites and spider nevi. What must you flag early?
Likely varices. Their care differs from ulcer care, so tell the team before endoscopy.
FAQ
Which Canadian guideline covers upper GI bleeding?
The 2019 international consensus, run through the Canadian Association of Gastroenterology. It covers bleeding that is not from varices. A 2022 joint guideline covers blood thinners during a bleed.
Does a normal first hemoglobin rule out a big bleed?
No. After sudden loss, hemoglobin can stay near its usual level at first. Judge the bleed by pulse, dizziness on standing, ongoing blood loss and repeat values.
Is hemoglobin in g/L or g/dL?
Canada uses g/L. A threshold of 80 g/L equals 8 g/dL. US guidelines and many papers write g/dL, so move the decimal one place.
Should I send a stool test when a patient sees blood?
No. Choosing Wisely Canada advises against guaiac tests to assess symptoms such as rectal bleeding. FIT is for screening people with no symptoms. Visible bleeding needs a direct look.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Gastroenterology guideline libraryCanadian Association of Gastroenterology
- Choosing Wisely recommendationsChoosing Wisely Canada