Massive gastrointestinal (GI) hemorrhage is a life-threatening condition that requires prompt recognition and resuscitation to increase the chance of good outcomes. Although no consensus definition exists, any gastrointestinal bleeding that results in hemodynamic instability, signs of poor perfusion (such as altered mental status, syncope, or pallor), transfusion of more than 2 units of packed red blood cells during the initial resuscitation, or overt and rapid bleeding can be considered massive.1 While mortality rates for all patients with GI bleeding range from 3% to 14%, mortality from massive upper GI bleeding is much higher.2 Prompt recognition of massive upper GI bleeding is of utmost importance for patients’ outcomes because an intensive hemodynamic care and early endoscopy are essential. Large bore vascular access for intensive fluid infusion, early aggressive transfusion, coagulation control, airway management, and appropriate medication selection are key components of managing these patients.2 Endoscopy should be performed within the first 24 h, but urgent endoscopy might offer some advantages in cases in which ongoing bleeding is suspected.3,4

Although upper GI bleeding has been thoroughly studied, massive forms are less known, as there are not large published series, and most conclusions regarding this disease have been drawn from meta-analyses and studies specifically addressing average GI bleeding.5 Indeed, an exhaustive review of the published papers on this topic offers mostly case reports, as well as reviews or papers focused on generalities or details about this problem.6,7 However, these patients can sometimes be overlooked by researchers in the field due to the high mortality rate in Emergency Departments (ED) or Intensive Care Units (ICU) and the rapid progression of their condition, often resulting in death before they can receive evaluation by Gastroenterologists or undergo endoscopy. This limitation restricts the possibility of comprehensive analysis. Eventually, this group of patients appears to exhibit distinct clinical characteristics, and gaining a better understanding of their unique clinical profile could provide insights to improve their management and increase their survival.

Therefore, the main aim of our study was to analyze differential characteristics, risk factors for the occurrence of massive gastrointestinal bleeding, and outcomes such as death and delayed deaths of these patients. Our goal was to achieve a better clinical understanding about this condition oriented towards improving early detection and management, whether in the (ED) or in the hospital ward and finding opportunities to increase survival.