What is the management approach for a patient with alcoholism (Alcohol Use Disorder) who presents with hematemesis (vomiting blood)?

Management of Hematemesis in Patients with Alcoholism

Patients with alcoholism who present with hematemesis require immediate medical attention and should be treated as a medical emergency due to the high risk of mortality from variceal bleeding.

Initial Assessment and Stabilization

• Airway, Breathing, Circulation (ABC):

  • Secure airway if patient has altered mental status
  • Establish large-bore IV access (at least two lines)
  • Start fluid resuscitation with crystalloids
  • Monitor vital signs continuously

• Laboratory Studies:

  • Complete blood count
  • Comprehensive metabolic panel
  • Coagulation studies (PT/INR, PTT)
  • Type and cross-match for blood products
  • Blood alcohol concentration

• Immediate Management:

  • Volume resuscitation with goal of hemodynamic stability
  • Blood transfusion if hemoglobin < 7-8 g/dL
  • Correct coagulopathy with fresh frozen plasma if INR > 1.5
  • Administer thiamine 100-300 mg/day to prevent Wernicke's encephalopathy 1

Specific Management for Variceal Bleeding

Variceal bleeding is the most common cause of hematemesis in alcoholics with liver disease:

1. Pharmacological Treatment:

   • Start vasoactive drugs immediately (before endoscopy):
     • Octreotide 50 μg IV bolus followed by 50 μg/hour infusion for 3-5 days
     • Terlipressin 2 mg IV every 4 hours (if available)

2. Antibiotic Prophylaxis:

   • Administer prophylactic antibiotics (ceftriaxone 1g IV daily) to prevent infections 2
   • Obtain cultures of blood, urine, and ascites (if present) regardless of fever 2

3. Endoscopic Management:

   • Perform urgent endoscopy within 12 hours of admission
   • Endoscopic band ligation is the preferred method for esophageal varices 3
   • Sclerotherapy may be used if banding is technically difficult

4. Rescue Therapy for Uncontrolled Bleeding:

   • Balloon tamponade (Sengstaken-Blakemore tube) as a temporary bridge
   • Transjugular intrahepatic portosystemic shunt (TIPS) for refractory bleeding

Management of Non-Variceal Causes

• Peptic Ulcer Disease:

  • High-dose proton pump inhibitor (e.g., pantoprazole 80 mg IV bolus followed by 8 mg/hour infusion)
  • Endoscopic therapy (injection, thermal, or mechanical methods)

• Mallory-Weiss Tears:

  • Usually self-limiting
  • Endoscopic therapy if active bleeding persists

Concurrent Management of Alcohol Withdrawal

• Assessment:

  • Monitor for signs of alcohol withdrawal using CIWA-Ar scale
  • Score > 8 indicates moderate withdrawal, ≥ 15 indicates severe withdrawal 2

• Treatment:

  • Benzodiazepines are the gold standard for alcohol withdrawal 2
  • For patients with hepatic dysfunction, use short-acting benzodiazepines (lorazepam, oxazepam) 2
  • Symptom-triggered regimen rather than fixed-dose schedule to prevent drug accumulation 2
  • Limit benzodiazepine use to 10-14 days due to abuse potential 2, 1

Nutritional Support

• Provide diet with 1-1.5 g protein and 30-40 kcal/kg body weight 2
• Consider enteral feeding via nasogastric tube if patient cannot eat
• Administer B-complex vitamins, especially thiamine

Long-term Management and Prevention

1. Alcohol Abstinence:

   • Abstinence is the cornerstone of treatment 2, 1
   • Refer to specialized alcohol addiction treatment

2. Pharmacotherapy for Alcohol Use Disorder:

   • For patients with liver disease: Baclofen (30-60 mg/day) is the first choice due to safety in cirrhosis 1
   • For patients with normal liver function:
     • Seeking abstinence: Acamprosate (666 mg TID)
     • Binge drinking pattern: Naltrexone (50 mg daily or 380 mg monthly injection) 1

3. Secondary Prophylaxis for Variceal Bleeding:

   • Non-selective beta-blockers (propranolol, nadolol)
   • Scheduled endoscopic band ligation sessions

4. Psychosocial Support:

   • Cognitive behavioral therapy
   • Support groups (Alcoholics Anonymous)
   • Family therapy and education

Common Pitfalls to Avoid

1. Delaying endoscopy in a patient with suspected variceal bleeding
2. Withholding benzodiazepines due to fear of respiratory depression in patients with alcohol withdrawal 1
3. Overaggressive fluid resuscitation which may increase portal pressure and worsen bleeding
4. Failure to recognize and treat concurrent infections, which increase mortality
5. Not addressing the underlying alcohol use disorder after acute management

By following this structured approach, the mortality associated with hematemesis in patients with alcoholism can be significantly reduced through prompt recognition, appropriate intervention, and comprehensive follow-up care.