What is the appropriate management for a patient with hematemesis?

Management of Hematemesis

The management of hematemesis requires immediate assessment, resuscitation, and a structured approach prioritizing hemodynamic stabilization before definitive intervention to reduce mortality and morbidity. 1

Initial Assessment and Resuscitation

Airway and Breathing

• Secure airway - consider endotracheal intubation in patients with massive hematemesis to prevent aspiration
• Administer oxygen to maintain adequate saturation

Circulation

• Establish two large-bore peripheral IV cannulae (16-18G) in anticubital fossae
• Initial crystalloid infusion of 1-2 L normal saline for volume resuscitation
• Classify severity based on:
  • Age >60 years
  • Pulse >100 beats/min
  • Systolic BP <100 mmHg
  • Hemoglobin <100 g/L

Laboratory Assessment

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

Blood Transfusion Strategy

• Transfuse when hemoglobin <70 g/L in most patients
• Target higher hemoglobin (>90 g/L) in patients with:
  • Massive bleeding
  • Cardiovascular comorbidities
• Correct coagulopathy:
  • Fresh frozen plasma (FFP) for prolonged PT/INR
  • Platelet transfusion to maintain count >75 × 10^9/L 2
  • Consider fibrinogen concentrate (30-60 mg/kg) or cryoprecipitate for hypofibrinogenemia

Pharmacological Management

• Start vasoactive agents before endoscopy:
  • Octreotide or terlipressin (especially for suspected variceal bleeding)
• Consider tranexamic acid in severe bleeding cases
• Administer proton pump inhibitors (high-dose IV)
• Prophylactic antibiotics for patients with cirrhosis

Endoscopic Management

• Perform urgent endoscopy within 6 hours for active, severe bleeding 1
• Endoscopy should only be performed after adequate resuscitation 2, 1
• Therapeutic interventions based on findings:
  • For non-variceal bleeding: thermal coagulation, hemoclips, or combination therapy
  • For variceal bleeding: endoscopic variceal ligation (EVL) for esophageal varices or endoscopic variceal obturation (EVO) for gastric varices 2
• Consider hemostatic powder application for immediate temporary control 2

Rescue Therapy for Failed Hemostasis

Failure to control bleeding is defined as:

• Fresh hematemesis ≥100 mL ≥2 hours after treatment
• Development of hypovolemic shock
• 3 g drop in hemoglobin within 24 hours without transfusion 2

Options include:

• TIPS (transjugular intrahepatic portosystemic shunt) - best rescue treatment for variceal bleeding with 90% success rate 2
• Balloon tamponade as bridge therapy (not to exceed 24 hours due to complications)
• Self-expandable esophageal covered metal stent as alternative to balloon tamponade
• Angiographic embolization if endoscopic therapy fails

Risk Stratification and Disposition

High-Risk Features (Require ICU/HDU Admission)

• Active hematemesis with hemodynamic instability
• Age >60 years
• Significant comorbidities
• Coagulopathy
• Suspected variceal bleeding (30% mortality) 3

Low-Risk Features (May Consider Discharge After Observation)

• Hemodynamically stable without orthostatic changes
• Age <60 years
• Hemoglobin >10 g/dL
• No significant comorbidities
• Reliable patient with good follow-up 4

Common Pitfalls to Avoid

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

Special Considerations

Liver Disease Patients

• More likely to develop coagulopathy with less blood loss
• May require higher volumes of FFP (at least 30 mL/kg) 2
• Early TIPS placement should be considered for Child-Pugh B cirrhosis with active bleeding or Child-Pugh C (score 10-13) 2

Patients on Anticoagulants/Antiplatelets

• Aspirin effect can be reversed with platelet transfusion
• P2Y12 inhibitors (clopidogrel) are only partially reversed by platelets 2
• Consider specific reversal agents based on anticoagulant type

Most upper GI bleeding (88%) stops spontaneously, but early intervention in high-risk cases is crucial to prevent the 6-10% mortality associated with this condition 5.