What are the management steps for a patient with hematemesis (vomiting blood)?

Management of Hematemesis

Immediate management of hematemesis requires rapid assessment, resuscitation, and control of bleeding through a structured approach prioritizing hemodynamic stabilization before definitive intervention. 1

Initial Assessment and Resuscitation

Hemodynamic Assessment

• Evaluate vital signs: pulse, blood pressure, respiratory rate
• Classify severity based on clinical parameters:
  • Severe bleeding: Age >60 years, pulse >100 beats/min, systolic BP <100 mmHg, hemoglobin <100 g/L 1
  • Mild bleeding: Stable vital signs, no significant comorbidities, younger patients 1, 2

Immediate Interventions

1. Secure airway - Consider endotracheal intubation in patients with massive hematemesis to prevent aspiration 1
2. Establish IV access - Insert two large-bore (8-Fr) peripheral IV cannulae in anticubital fossae 1
3. Fluid resuscitation:
   • Initial crystalloid infusion (1-2 L normal saline) 1
   • If patient remains shocked after initial fluid resuscitation, administer plasma expanders 1
   • Blood transfusion when:
     • Hemoglobin <100 g/L in acute bleeding
     • Active hematemesis with shock 1
     • Target hemoglobin >70 g/L (>90 g/L in patients with massive bleeding or cardiovascular comorbidities) 1

Laboratory Assessment

• Complete blood count, coagulation profile (PT, aPTT, fibrinogen)
• Type and cross-match for blood products
• Serum lactate and base deficit to estimate bleeding severity 1
• Liver and renal function tests 1

Monitoring

• Continuous vital sign monitoring with automated devices
• Urinary catheter insertion with hourly output measurement (target >30 mL/hr) 1
• Central venous pressure monitoring in patients with cardiac disease 1

Endoscopic Management

Timing of Endoscopy

• Urgent endoscopy (within 6 hours) for patients with active, severe bleeding 1, 3
• Semi-elective endoscopy for stabilized patients with minor bleeding 1
• Endoscopy should only be performed after adequate resuscitation 1

Endoscopic Procedure

• Should be performed by experienced endoscopists capable of therapeutic interventions 1
• Consider endotracheal intubation before endoscopy in patients with severe bleeding 1
• Identify bleeding source and apply appropriate therapeutic intervention:
  • For ulcers: thermal coagulation, injection therapy, or hemostatic clips 4
  • For varices: band ligation or sclerotherapy 3, 4
  • Consider hemostatic powders for temporary control of active bleeding 3

Management Based on Bleeding Source

Non-variceal Bleeding

• Initiate proton pump inhibitor therapy
• Endoscopic therapy for high-risk lesions (active bleeding, visible vessels)
• Consider angiographic embolization if endoscopic therapy fails 1

Variceal Bleeding

• Administer vasoactive drugs (octreotide 50 mcg bolus then 25 mcg/hour for 24 hours) 3
• Prophylactic antibiotics (ceftriaxone 1g IV) for cirrhotic patients 3
• Endoscopic band ligation or sclerotherapy 3, 4
• Consider transjugular intrahepatic portosystemic shunt (TIPS) for refractory bleeding

Coagulopathy Management

• Correct coagulopathy with appropriate blood products:
  • Fresh frozen plasma (15 mL/kg) for prolonged PT/aPTT 1
  • Platelet transfusion to maintain count >75 × 10⁹/L 1, 5
  • Cryoprecipitate or fibrinogen concentrate to maintain fibrinogen >1.5 g/L 5
• Consider tranexamic acid (10-15 mg/kg followed by infusion of 1-5 mg/kg/h) in cases of severe bleeding 1

Disposition and Follow-up

• Admit patients with severe bleeding to intensive care or high-dependency unit
• Low-risk patients (age <60, no orthostatic changes, hemoglobin >10 g/dL, no significant comorbidities) may be discharged after 6-hour observation 2
• Arrange follow-up endoscopy as needed for definitive therapy 3

Common Pitfalls

• Delaying resuscitation while waiting for endoscopy
• Performing endoscopy before adequate resuscitation
• Failing to identify patients with liver disease who require specific management
• Overlooking the need for prophylactic antibiotics in cirrhotic patients
• Not implementing venous thromboprophylaxis after bleeding is controlled 1

Recent evidence suggests that most upper GI bleeding (88%) stops spontaneously, with only 6% of patients requiring therapeutic endoscopic intervention and virtually none requiring surgical or interventional radiologic procedures 6. However, prompt assessment and appropriate management remain essential as mortality rates for upper GI bleeding remain around 6-10% 6.