Treatment for Hematemesis
The management of hematemesis requires immediate resuscitation with fluid replacement, airway protection, and urgent endoscopy within 6-12 hours after hemodynamic stabilization to identify and treat the bleeding source. 1
Initial Assessment and Resuscitation
Hemodynamic Stabilization
- Insert two large-bore peripheral IV cannulae in anticubital fossae 2, 1
- Initial fluid resuscitation with 1-2 liters of normal saline 2, 1
- If patient remains shocked after initial fluid resuscitation, administer plasma expanders 2, 1
- Target adequate urine output (>30 ml/h) and central venous pressure (5-10 cm H₂O) 2, 1
- Consider inserting urinary catheter for hourly volume measurement in severe cases 2
Blood Transfusion Criteria
- Transfuse red blood cells when 2, 1:
- Hemoglobin <100 g/L in acute bleeding
- Active hematemesis with shock
- Target hemoglobin of 7-9 g/dL (restrictive strategy)
Airway Protection
- Consider endotracheal intubation for 1:
- Active hematemesis
- Inability to maintain or protect airway
- Need for optimal sedation during endoscopy
Diagnostic Approach
Urgent Endoscopy
- Perform endoscopy within 6-12 hours after adequate resuscitation 1
- Should only be performed by experienced endoscopists capable of therapeutic interventions 2, 1
- Consider CT angiography before colonoscopy if lower GI source is suspected 2
Risk Assessment
- Evaluate severity based on 2, 1:
- Age >60 years
- Pulse >100 beats/min
- Systolic BP <100 mmHg
- Hemoglobin <100 g/L
Specific Treatments Based on Etiology
Non-Variceal Bleeding (e.g., Peptic Ulcers)
- Endoscopic interventions 1, 3:
- Thermal coagulation
- Hemoclips
- Injection with dilute adrenaline, thrombin, or fibrin glue
- Combination therapy
- Pharmacological therapy:
- Intravenous proton pump inhibitors (e.g., omeprazole) 3
Variceal Bleeding
- Pharmacological therapy 1:
- Vasoactive drugs: Octreotide 50 μg IV bolus (can be repeated in first hour)
- Continuous IV infusion of octreotide 50 μg/h for 2-5 days
- Endoscopic therapy 1, 4:
- Endoscopic variceal ligation (EVL) for esophageal varices (preferred due to lower complication rate)
- Endoscopic variceal obturation (EVO) for gastric varices
- Prophylactic antibiotics: IV ceftriaxone 1 g/24h (maximum 7 days) 1
- Consider early TIPS placement for Child-Pugh B cirrhosis with active bleeding or Child-Pugh C 1
Coagulation Management
- Correct coagulopathy with fresh frozen plasma for prolonged PT/INR 1
- Maintain platelet count >75 × 10^9/L 1
- Consider tranexamic acid in cases of severe bleeding 1, 5
Management of Rebleeding
Definition of Rebleeding
- Fresh hematemesis ≥100 mL ≥2 hours after treatment
- Development of hypovolemic shock
- 3 g drop in hemoglobin within 24 hours without transfusion 1
Rescue Therapies
- Repeat endoscopic therapy 3
- TIPS (transjugular intrahepatic portosystemic shunt) with a 90% success rate 1
- Balloon tamponade or self-expandable esophageal covered metal stent 1
- Angiographic embolization if endoscopic therapy fails 1
- Surgical intervention if other methods fail 3
Disposition and Monitoring
- Admit patients with severe bleeding to intensive care or high-dependency unit 1
- Continuous monitoring of vital signs using automated devices 2, 1
- Most patients (88%) will stop bleeding spontaneously, but close monitoring is essential 6
Common Pitfalls to Avoid
- Delaying resuscitation while waiting for endoscopy 1
- Performing endoscopy before adequate resuscitation 1
- Failing to identify patients with liver disease who require specific management 2, 1
- Overlooking the need for prophylactic antibiotics in cirrhotic patients 1
- Neglecting airway protection in patients with active hematemesis 1
Remember that while therapeutic endoscopic intervention is only required in about 6% of patients 6, early and appropriate resuscitation followed by timely endoscopy is essential for optimal outcomes and reduced mortality.