What is the initial workup for a patient presenting with hematemesis?

Initial Workup for Hematemesis

The initial workup for a patient presenting with hematemesis should include immediate assessment of hemodynamic status, establishment of adequate IV access with two large-bore peripheral cannulae, fluid resuscitation, airway protection if needed, and urgent endoscopy after stabilization to identify and treat the bleeding source. 1, 2

Initial Assessment and Resuscitation

Hemodynamic Assessment

• Evaluate vital signs to classify severity of bleeding 1, 2:
  • Severe bleeding: Age >60 years, pulse >100 beats/min, systolic BP <100 mmHg, hemoglobin <100 g/L
  • Use automated monitoring devices for continuous vital sign tracking
  • Insert urinary catheter and measure hourly output in severe cases

Airway Management

• Consider endotracheal intubation for 1, 2:
  • Active hematemesis
  • Inability to maintain or protect airway
  • Need for optimal sedation during endoscopy

Vascular Access and Fluid Resuscitation

• Insert two large-bore peripheral IV cannulae in anticubital fossae 1, 2
• Initial fluid resuscitation with 1-2 liters of normal saline 1
• If patient remains shocked after initial fluid resuscitation, administer plasma expanders 1
• Target adequate urine output (>30 ml/h) and central venous pressure (5-10 cm H₂O) 1

Blood Transfusion Strategy

• Transfuse red blood cells when 1, 2:
  • Hemoglobin <100 g/L in acute bleeding
  • Active hematemesis with shock
  • Target hemoglobin of 7-9 g/dL (restrictive strategy)
  • Higher threshold (>90 g/L) may be appropriate for patients with cardiovascular comorbidities

Laboratory Evaluation

• Complete blood count
• Coagulation profile (PT/INR, PTT)
• Liver function tests (to identify patients with liver disease who require specific management)
• Renal function tests
• Type and cross-match for blood products
• Serum lactate and base deficit to estimate bleeding severity 2

Medication Administration

• For suspected variceal bleeding 1:
  • Vasoactive drugs: Octreotide 50 μg IV bolus (can be repeated in first hour if ongoing bleeding)
  • Continuous IV infusion of octreotide 50 μg/h for 2-5 days
  • Prophylactic antibiotics: IV ceftriaxone 1 g/24h (maximum 7 days)

Coagulopathy Correction

• Fresh frozen plasma for prolonged PT/INR 2
• Platelet transfusion to maintain count >75 × 10^9/L 2
• Consider tranexamic acid in severe bleeding 2

Endoscopic Evaluation

Timing of Endoscopy

• Urgent endoscopy (within 6-12 hours) after adequate resuscitation 1, 2
• Should only be performed after hemodynamic stabilization 1
• Performed by experienced endoscopists capable of therapeutic interventions 1, 2

Endoscopic Preparation

• Consider administration of erythromycin (250 mg IV, 30-120 min before endoscopy) to improve visualization 1
• Check QT interval before erythromycin administration 1

Endoscopic Findings and Intervention

• Identify the bleeding source and remove adherent blood clot to expose accurate target for therapy 1
• Apply appropriate therapeutic intervention based on findings 2:
  • Non-variceal bleeding: Thermal coagulation, hemoclips, or combination therapy
  • Esophageal varices: Endoscopic variceal ligation (EVL)
  • Gastric varices: Endoscopic variceal obturation (EVO)
  • Consider hemostatic powder application for immediate temporary control

Post-Endoscopy Management

Monitoring for Rebleeding

• Define rebleeding as 1, 2:
  • Fresh hematemesis ≥100 mL ≥2 hours after treatment
  • Development of hypovolemic shock
  • 3 g drop in hemoglobin within 24 hours without transfusion

Rescue Therapies for Failed Endoscopic Control

• Consider TIPS (transjugular intrahepatic portosystemic shunt) for variceal bleeding 2
• Angiographic embolization if endoscopic therapy fails 2
• Surgical consultation for persistent bleeding not controlled by endoscopic or radiological interventions

Disposition

• Admit patients with severe bleeding to intensive care or high-dependency unit 1
• Low-risk patients may be discharged after 6-hour observation, but should be carefully selected 2

Common Pitfalls to Avoid

• Delaying resuscitation while waiting for endoscopy 2
• Performing endoscopy before adequate resuscitation 1, 2
• Failing to identify patients with liver disease who require specific management 1
• Overlooking the need for prophylactic antibiotics in cirrhotic patients 2
• Not implementing venous thromboprophylaxis after bleeding is controlled 2

It's important to note that while most upper GI bleeding episodes (65%) stop spontaneously, 25% bleed recurrently and 10% persist 3. Early endoscopic evaluation and intervention have been shown to reduce mortality in patients with hematemesis 3, 4.