What is the appropriate workup for a patient presenting with hematemesis (vomiting blood) in an outpatient gastrointestinal (GI) setting?

Workup for Hematemesis in Outpatient GI Setting

For patients presenting with hematemesis in an outpatient GI setting, upper GI endoscopy (esophagogastroduodenoscopy) should be performed within 24 hours, with earlier endoscopy (within 12 hours) for high-risk patients to reduce morbidity and mortality. 1

Initial Assessment and Stabilization

• Immediately assess hemodynamic stability:

  • Check vital signs (pulse, blood pressure)
  • Shock index (heart rate/systolic BP) > 1 indicates instability 2
  • Look for orthostatic changes and signs of ongoing bleeding

• Laboratory evaluation:

  • Complete blood count
  • Basic metabolic panel
  • Coagulation panel
  • Liver function tests
  • Type and crossmatch 3

• Risk stratification:

  • Use Glasgow-Blatchford bleeding score to determine urgency of intervention 3
  • Age >60 years is a significant risk factor requiring immediate attention 1

Diagnostic Algorithm

For Hemodynamically Unstable Patients:

1. Rapid volume resuscitation is the first priority 2
2. CT Angiography (CTA) should be the first investigation for actively bleeding, unstable patients
   • High sensitivity (80-90%) for detecting bleeding at rates of 0.3-1.0 mL/min 1
   • Can identify bleeding sources throughout the GI tract 2
3. If CTA is negative but suspicion remains high for upper GI source, proceed to urgent upper endoscopy 2

For Hemodynamically Stable Patients:

1. Upper GI endoscopy within 24 hours (within 12 hours for high-risk patients) 1
   • Successfully identifies bleeding source in 95% of cases 2
   • Allows for simultaneous therapeutic intervention
   • Provides prognostic information regarding rebleeding risk 2

If Initial Endoscopy is Negative:

1. Consider video capsule endoscopy (VCE) if small bowel source is suspected

   • Highest diagnostic yield (87-91.9%) when performed within 48 hours of bleeding 1
   • Yield drops to <50% if performed after 3 days 2

2. Additional options if source remains unidentified:

   • Nuclear medicine studies (tagged RBC scintigraphy) - sensitivity 60-93% 2, 1
   • Mesenteric angiography (limited value if CTA already negative) 2

Management Considerations

• Start high-dose proton pump inhibitor therapy immediately while awaiting definitive diagnosis 1, 3

• Medication review and management:

  • Discontinue NSAIDs as they can exacerbate GI bleeding 1
  • Manage antiplatelet/anticoagulant therapy in consultation with cardiology 1
  • Consider reversal agents for anticoagulants in life-threatening hemorrhage 1

• Endoscopic treatment options for identified bleeding:

  • Band ligation
  • Sclerotherapy
  • Hemostatic clips
  • Combination therapy with epinephrine and another modality 1

Important Caveats

• Do not place nasogastric tubes routinely in suspected upper GI bleeding - they don't reliably aid diagnosis, don't affect outcomes, and have complications in up to one-third of patients 2, 1

• Remember that up to 15% of patients with suspected lower GI bleeding ultimately have an upper GI source 1

• Consider angiographic embolization for patients with ongoing bleeding not amenable to endoscopic treatment 1

• Recognize that 25% of patients experience rebleeding after initial cessation, with 75% of rebleeding occurring within the first two days 4

• Ensure follow-up includes iron supplementation for patients with anemia (response rate 80-90%) 1

• Perform age-appropriate cancer screening as GI malignancies can present with hematemesis 1