What is the management of hematemesis (vomiting blood)?

From the Guidelines

Haematemesis management involves immediate assessment and stabilization of the patient, with the administration of vasoactive drugs such as terlipressin or octreotide, and urgent endoscopy within 12 hours for diagnosis and potential therapeutic intervention, as recommended by the most recent guidelines 1.

Initial Assessment and Stabilization

The initial management of haematemesis involves securing the airway, ensuring adequate breathing, and establishing intravenous access with two large-bore cannulas (16-18G). Administer crystalloid fluids like normal saline or Ringer's lactate for volume resuscitation. For severe bleeding, transfuse packed red blood cells to maintain hemoglobin above 7-8 g/dL (or higher in patients with cardiac disease).

Vasoactive Drug Therapy

Vasoactive drugs such as terlipressin 2mg IV every 4-6 hours or octreotide 50mcg IV bolus followed by 50mcg/hour infusion can be used if variceal bleeding is suspected, as recommended by the EASL clinical practice guidelines 1.

Endoscopy and Therapeutic Intervention

Arrange urgent endoscopy within 12 hours (sooner in severe cases) for diagnosis and potential therapeutic intervention such as clipping, thermal coagulation, or band ligation, as recommended by the EASL clinical practice guidelines 1. Administer erythromycin 250mg IV 30-120 minutes before endoscopy to improve visualization.

Prevention of Complications

Prevention of complications such as bacterial infections, hepatic encephalopathy, and deterioration of renal function should run simultaneously to haemostatic therapies from admission of patients with cirrhosis and acute GI bleeding, as recommended by the EASL clinical practice guidelines 1. Antibiotic prophylaxis with ceftriaxone (1 g/24 h) for up to seven days is recommended to reduce the incidence of infections and improve control of bleeding and survival.

Management of Underlying Cause

After stabilization, identify and treat the underlying cause, which may include H. pylori eradication, discontinuation of NSAIDs, or management of portal hypertension. Early involvement of gastroenterology, intensive care, and surgical teams is essential for optimal management of this potentially life-threatening condition.

Note: The management of haematemesis should prioritize the prevention of morbidity, mortality, and improvement of quality of life, and should be based on the most recent and highest quality evidence available, as recommended by the EASL clinical practice guidelines 1.

From the Research

Management of Hematemesis

The management of hematemesis, or vomiting blood, involves several key steps and considerations.

• Initial treatment includes stabilization of the patient, with protection of the airway, fluid resuscitation, and blood transfusions as needed 2, 3.
• The choice of fluid for resuscitation may include colloids or crystalloids, with evidence suggesting that there is little difference in outcomes between the two, although colloids may be associated with a higher risk of adverse events 4.
• Endoscopy is a crucial diagnostic and therapeutic tool in the management of hematemesis, allowing for the identification and treatment of bleeding lesions 5, 6, 3.
• Treatment of bleeding lesions may involve the use of medications such as pantoprazole, which has been shown to be effective in controlling bleeding in patients with acute gastrointestinal bleeding 5.
• Other treatments, such as octreotide, may also be used to control bleeding, particularly in cases of variceal hemorrhage 6.
• In children, the management of upper gastrointestinal bleeding involves stabilization, fluid resuscitation, and endoscopy, with a focus on using combinations of therapies to treat bleeding lesions 3.

Treatment Options

Treatment options for hematemesis may include:

• Medications such as pantoprazole and octreotide to control bleeding 5, 6
• Endoscopy with therapies such as epinephrine injection, cautery, hemoclips, and hemospray to treat bleeding lesions 5, 6, 3
• Fluid resuscitation with colloids or crystalloids to stabilize the patient 4
• Blood transfusions as needed to maintain a transfusion hemoglobin threshold of 7 g/L 3

Special Considerations

Special considerations in the management of hematemesis include:

• The need for prompt stabilization and treatment to prevent complications and improve outcomes 2, 3
• The importance of endoscopy in diagnosing and treating bleeding lesions 5, 6, 3
• The potential risks and benefits of different treatment options, including medications and fluid resuscitation strategies 5, 6, 4