What is the appropriate workup and management for a patient with hematemesis and a significant drop in hemoglobin, but a negative endoscopy?

Management of Hematemesis with Significant Hemoglobin Drop and Negative Endoscopy

For a patient with hematemesis and significant hemoglobin drop but negative endoscopy, further investigation is necessary before discharge, as the source of bleeding must be identified to prevent recurrence and potential complications. 1

Initial Assessment After Negative Endoscopy

• Ensure the patient is hemodynamically stable with adequate resuscitation (normal pulse, blood pressure, and urine output) 1, 2
• Assess for ongoing bleeding signs despite negative endoscopy (continued hemoglobin drop, tachycardia, hypotension) 1, 2
• Calculate a risk score such as the Rockall score to help determine prognosis and management 1

Further Diagnostic Workup

For Hemodynamically Unstable Patients:

• Perform CT angiography (CTA) immediately as it provides the fastest means to localize the bleeding site 1
• CTA can detect bleeding rates as low as 0.3 mL/min and has 81% sensitivity in high-risk patients 1
• If CTA is positive, proceed to catheter angiography with potential embolization within 60 minutes 1
• If no source is identified on CTA, repeat upper endoscopy should be considered 1, 2

For Hemodynamically Stable Patients:

• CT enterography to evaluate small bowel sources not visualized on standard endoscopy 1
• Consider second-look endoscopy if clinical suspicion remains high 1, 2
• Tc-99m-labeled RBC scan can be useful for detecting intermittent or slow bleeding (rates as low as 0.05 mL/min) 1

Management Decision Algorithm

1. Hemodynamically unstable with active bleeding:

   • Continue resuscitation with IV fluids and blood products as needed 2
   • Proceed to CTA followed by potential angiographic intervention 1
   • Hospital admission is mandatory 1

2. Hemodynamically stable with significant hemoglobin drop (>2 g/dL):

   • Admit for observation and further investigation 1, 2
   • Monitor vital signs, hemoglobin levels, and urine output 1, 2
   • Consider CT enterography or second-look endoscopy 1

3. Hemodynamically stable with minor hemoglobin drop (<2 g/dL) and self-terminating bleed:

   • If Oakland score ≤8 points and no other indications for admission, can consider discharge with urgent outpatient investigation 1
   • Ensure patient meets discharge criteria: age <60 years, hemoglobin >10 g/dL, no orthostatic changes, no significant comorbidities, and reliable for follow-up 3, 4

Important Considerations

• Up to 75% of recurrent bleeding occurs within the first 48 hours after initial hemorrhage 5
• Non-GI explanations for hematocrit drops should be considered, including sepsis, volume shifts, and post-procedural bleeding 6
• Patients with clean-based duodenal ulcers and stable vital signs have low rebleeding risk and may be candidates for early discharge 4
• Rare causes of hematemesis such as gastric diverticula should be considered when standard endoscopy is negative 7

Discharge Criteria After Negative Endoscopy

Patients can be considered for discharge if they meet ALL of the following:

• Hemodynamically stable for at least 6 hours 3
• No orthostatic vital sign changes 3
• Hemoglobin >10 g/dL with no significant drop on repeat testing 3, 4
• Age <60 years 3
• No significant comorbidities 3
• Reliable for follow-up and able to return promptly if symptoms recur 3, 4
• Oakland score ≤8 points 1

If any of these criteria are not met, hospital admission for further monitoring and investigation is recommended 1.