How to manage a ca esophagus patient with massive hematemesis?

Management of Massive Hematemesis in Esophageal Cancer Patients

Immediate control of bleeding and aggressive resuscitation are the cornerstones of managing massive hematemesis in esophageal cancer patients, with early consideration of endovascular stent-graft placement for suspected aortoesophageal fistula. 1, 2

Initial Resuscitation and Stabilization

Immediate Actions

• Control obvious bleeding points using direct pressure and hemostatic dressings
• Administer high concentration oxygen
• Establish large-bore IV access (preferably 8-Fr central access in adults)
• Assess hemodynamic status (if patient is conscious with palpable peripheral pulse, blood pressure is adequate) 1
• Obtain baseline blood tests:
  • Full blood count (FBC)
  • Prothrombin time (PT)
  • Activated partial thromboplastin time (aPTT)
  • Clauss fibrinogen (not derived fibrinogen)
  • Blood typing and cross-matching 1

Fluid Resuscitation

• Use warmed blood products for resuscitation
• Follow blood product administration in order of availability:
  • O-negative (fastest)
  • Type-specific
  • Cross-matched blood 1, 3
• Implement high-ratio transfusion strategy (at least 1 unit plasma per 2 units RBCs)
• Maintain fibrinogen levels >1.5 g/L using cryoprecipitate or fibrinogen concentrate
• Consider platelet transfusion for significant active bleeding (target >75 × 10⁹/L) 3
• Actively warm the patient and all transfused fluids 1

Diagnostic Approach

Urgent Endoscopy

• Perform urgent upper endoscopy to:
  • Identify bleeding source
  • Assess tumor involvement
  • Rule out other causes (varices, Mallory-Weiss tear) 4
  • Guide immediate therapeutic interventions

Imaging

• Consider CT angiography if endoscopy cannot identify source or if aortoesophageal fistula is suspected
• Look for signs of internal bleeding and assess extent through appropriate imaging 1, 2

Specific Management Based on Etiology

Tumor-Related Bleeding

• Endoscopic interventions:
  • Injection therapy
  • Thermal coagulation
  • Hemostatic clips or sprays
  • Consider endoscopic sclerotherapy for varices if present 4

Aortoesophageal Fistula

• High mortality condition requiring urgent intervention
• Endovascular stent-graft placement is an effective emergency treatment 2
• Surgical consultation for potential definitive management

Ongoing Management

Monitoring and Support

• Admit to critical care unit for close monitoring
• Regular assessment of:
  • Coagulation parameters (every 30-60 minutes during active bleeding)
  • Hemoglobin
  • Blood gases 1, 3
• Correct hypocalcemia and hypomagnesemia associated with massive transfusions 3

Definitive Management

• Early surgical or interventional radiology consultation
• Consider bronchial artery embolization if appropriate 5
• Damage control approach may be necessary in unstable patients 1

Post-Bleeding Care

• Initiate standard venous thromboprophylaxis once bleeding is controlled
• Consider temporary inferior vena cava filtration in high-risk cases 1
• Monitor for rebleeding, which carries high mortality

Common Pitfalls and Caveats

• Don't delay resuscitation while waiting for diagnostic procedures
• Don't underestimate blood loss - patients may compensate well despite significant hemorrhage
• Consider aortoesophageal fistula in any esophageal cancer patient with massive hematemesis, especially after radiation therapy 2, 6
• Avoid vasopressors if possible as they may worsen bleeding
• Don't forget coagulopathy management - dilutional and consumptive coagulopathy are common in massive hemorrhage 1
• Establish clear communication - appoint a team leader and communications lead to coordinate care 1