anemia suggests chronic mucosal bleeding Initial low white blood cell and platelet counts may be seen in either hypersplenism from portal hypertension or sepsis with associated mucosal ulceration due to stress Abnormal hepatic studies, including an elevation of serum bilirubin, transaminases, and prothrombin time, and a low serum albumin, are suggestive of esophageal varices A blood urea nitrogen to creatinine ratio greater than 30 may indicate blood resorption and an upper GI source of bleeding Diagnostic Approach If a significant upper GI bleed has occurred, and once hemodynamic stability is restored, identification of the specific age-related disorder is the next step ( Table 33.1 and Fig 33.2 ) If the bleeding is mild and self-limited or the gastric aspirate is negative, a minor mucosal lesion is likely Although mucosal lesions such as esophagitis, gastritis, or peptic ulcer disease can present with severe bleeding, most often bleeding from mucosal lesions is self-limiting and will respond to conservative medical management In patients who present with concern for swallowed foreign body, obstruction, or perforation plain x-ray radiographs of the chest or abdomen may be diagnostic Abdominal ultrasonography can be helpful in patients where esophageal varices, liver disease, or portal hypertension are a concern Upper GI contrast radiography can be helpful in determining obstructions and other irregularities of the GI tract, but should not be performed in the setting of persistent or recurrent bleeding In this setting, endoscopy should be considered prior to the use of contrast radiography in which contrast material obscures the bleeding source