What is the treatment for hematemesis (bloody vomiting)?

Treatment for Hematemesis (Bloody Vomiting)

The treatment for hematemesis requires immediate assessment of severity, rapid resuscitation with IV fluids, blood transfusion when hemoglobin is below 100 g/L, and urgent endoscopy after stabilization to identify and treat the bleeding source. 1

Initial Assessment and Resuscitation

Severity Classification

• Mild/Moderate: Stable vital signs, no significant hemodynamic compromise
• Severe: Age >60 years, pulse >100 beats/min, systolic BP <100 mmHg, hemoglobin <100 g/L 2, 1

Immediate Interventions

1. Establish IV Access

   • Insert two large-bore venous cannulae in anticubital fossae 2, 1
   • Begin fluid resuscitation with normal saline (1-2 liters initially) 2
   • If patient remains shocked after initial fluids, administer plasma expanders 2

2. Airway Protection

   • Consider endotracheal intubation for active hematemesis to prevent aspiration 1
   • Especially important in patients with altered mental status or massive bleeding

3. Blood Transfusion

   • Transfuse red blood cells when:
     • Hemoglobin <100 g/L in acute bleeding
     • Active hematemesis with shock
     • Target hemoglobin 70-90 g/dL (restrictive strategy) 2, 1

4. Monitoring

   • Continuous vital sign monitoring with automated devices
   • Insert urinary catheter and monitor hourly urine output (target >30 mL/h)
   • Monitor central venous pressure (target 5-10 cm H₂O) in patients with cardiac disease 2

Endoscopic Management

Timing of Endoscopy

• Perform endoscopy only after adequate resuscitation and hemodynamic stabilization 2, 1
• Urgent endoscopy (within 6-12 hours) for severe bleeding 1
• For low-risk young patients with minor bleeding, endoscopy may not be necessary 2

Endoscopic Interventions Based on Cause

1. Peptic Ulcer Disease

   • Injection therapy: Dilute adrenaline, thrombin, or fibrin glue 3
   • Thermal methods: Heater probe (20-30 joules), multipolar electrocoagulation, Argon plasma coagulation 2
   • Mechanical clips for actively bleeding vessels 2
   • Combination therapy (adrenaline injection plus thermal methods) may be superior for active arterial bleeding 2

2. Variceal Bleeding

   • Vasoactive drugs: Octreotide 50 μg IV bolus followed by continuous infusion 1
   • Endoscopic variceal ligation (EVL) for esophageal varices 1
   • Endoscopic variceal obturation (EVO) for gastric varices 1
   • Prophylactic antibiotics: IV ceftriaxone 1 g/24h for up to 7 days 1

3. Mallory-Weiss Tears

   • Usually stop bleeding spontaneously
   • Endoscopic therapy (adrenaline injection or thermal methods) for severe cases 2

4. Vascular Malformations

   • Argon Plasma Coagulator or heater probe application 2
   • May require multiple sessions for complete hemostasis

Pharmacological Management

1. Acid Suppression

   • High-dose proton pump inhibitor therapy after successful endoscopic therapy:
     • Omeprazole 80 mg IV bolus followed by 8 mg/hour infusion for 72 hours 2
   • Reduces rebleeding, blood transfusion requirements, and hospital stay 2

2. For Suspected Variceal Bleeding

   • Terlipressin or octreotide before endoscopic confirmation 2, 1

Post-Endoscopy Management

• Continue close monitoring of vital signs and urine output
• Allow patients to drink and start light diet 4-6 hours after endoscopy if hemodynamically stable 2
• Monitor for signs of rebleeding: fresh hematemesis ≥100 mL ≥2 hours after treatment, hypovolemic shock, or 3 g drop in hemoglobin within 24 hours 1

Management of Rebleeding or Failed Endoscopic Therapy

• Repeat endoscopic therapy
• Consider angiography and embolization for ongoing bleeding 2
• Surgical intervention if endoscopic and angiographic approaches fail
• For variceal bleeding: Consider TIPS (transjugular intrahepatic portosystemic shunt) 1

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 the need for prophylactic antibiotics in cirrhotic patients 1
• Excessive fluid resuscitation can worsen bleeding in certain conditions 4

Recent data suggests that most upper GI bleeding (88%) stops spontaneously, with only 6% requiring therapeutic endoscopic intervention and rarely needing surgical or interventional radiologic procedures 5. However, mortality remains significant at 6-10%, highlighting the importance of prompt and appropriate management 5, 6.