What is the management of hematemesis?

Management of Hematemesis

The immediate management of hematemesis requires activation of a hospital's major hemorrhage protocol, control of bleeding, hemodynamic stabilization, and early endoscopic intervention within 36 hours of onset for optimal outcomes. 1, 2

Initial Assessment and Stabilization

• Immediate actions:

  • Control obvious bleeding points (pressure, tourniquet, haemostatic dressings) 1
  • Administer high FiO2
  • Establish large-bore IV access (including central access if needed)
  • Assess hemodynamic status (if patient is conscious, talking, and has a peripheral pulse, blood pressure is adequate) 1

• Laboratory assessment:

  • Baseline blood tests: FBC, PT, aPTT, Clauss fibrinogen, and cross-match 1
  • Near-patient testing if available (thromboelastography or thromboelastometry)
  • Repeat coagulation tests every 30-60 minutes during active bleeding 3

Blood Product Administration

• Red blood cells:

  • Initiate warmed blood transfusion for massive hemorrhage 1
  • Consider high-ratio transfusion strategy (1:1:1 RBC:plasma:platelets) for severe cases 3

• Platelets:

  • Maintain platelet count >75 × 10⁹/L in massive hemorrhage 3
  • Transfuse platelets for severe thrombocytopenia (<35 × 10⁹/L) with active bleeding 3

• Coagulation factors:

  • Administer FFP (15 ml/kg) early if massive hemorrhage is anticipated 1
  • Consider cryoprecipitate if fibrinogen <1.5 g/L 3
  • Target fibrinogen >1.5 g/L and PT/aPTT <1.5 times normal 3

Pharmacological Management

• Consider tranexamic acid if evidence of hyperfibrinolysis: loading dose of 1g over 10 minutes, followed by 1g over 8 hours 3
  • Note: FDA-approved indication for tranexamic acid is limited to hemophilia patients undergoing tooth extraction 4, but its use in acute bleeding is supported by guidelines

Endoscopic Management

• Perform endoscopy within the first 36 hours of bleeding onset for highest success rate 2
• Therapeutic endoscopic intervention (required in approximately 6% of cases) may include: 5
  • Band ligation for esophageal varices
  • Cyanoacrylate injection for gastric varices
  • Hemostatic powder application for temporary control of variceal bleeding 6
  • Laser therapy or ethanol injection for gastric ulcers with exposed vessels 7

Ongoing Management

• Admit to critical care for monitoring and observation 1, 3
• Continue monitoring coagulation parameters, hemoglobin, and blood gases
• Assess for rebleeding (which carries high mortality) 3
• Initiate standard venous thromboprophylaxis once bleeding is controlled 1, 3

Prognosis and Risk Stratification

• Overall mortality rate is approximately 6-10% 5
• Higher mortality (up to 30%) if bleeding is from varices 2
• 65% of hemorrhages subside spontaneously, 25% bleed recurrently, and 10% have persistent bleeding 2
• Three-quarters of rebleeding occurs within two days of initial hemorrhage 2
• Patients with mild hematemesis, stable cardiovascular parameters, and no risk factors may be managed as outpatients 2, 8

Discharge Criteria

Patients with hematemesis may be safely discharged after 6 hours of observation if they meet all criteria: 8

• No orthostatic vital sign changes
• No significant underlying disease
• Hemoglobin >10 g/dL
• Age <60 years
• Reliable and compliant with follow-up

Common Pitfalls to Avoid

• Delaying activation of the major hemorrhage protocol
• Failing to control obvious bleeding points immediately
• Not repeating coagulation tests frequently during active bleeding
• Overlooking the need for early endoscopy (within 36 hours)
• Neglecting to initiate thromboprophylaxis once bleeding is controlled
• Underestimating the risk of rebleeding, especially within the first 48 hours