What is the initial workup for a patient presenting with new onset hematemesis?

Initial Workup for New Onset Hematemesis

Immediately assess hemodynamic stability and secure large-bore IV access while simultaneously initiating resuscitation and arranging urgent upper endoscopy within 24 hours of presentation. 1, 2

Immediate Assessment and Stabilization

Hemodynamic Evaluation

• Assess severity using vital signs and clinical presentation: pulse >100 bpm, systolic BP <100 mmHg, altered mental status, and active hematemesis indicate severe bleeding requiring aggressive intervention 3, 1
• Measure shock index (heart rate/systolic BP) and pulse pressure to assess hypovolemic shock and transfusion requirements 3, 1
• Secure two large-bore (ideally 8-Fr) IV cannulae in the anticubital fossae for patients with hemodynamic compromise 3, 1
• Insert urinary catheter and monitor hourly urine output (target >30 mL/hour) 3

Initial Laboratory Studies

• Obtain complete blood count, PT, aPTT, and fibrinogen levels immediately 4, 1
• Do not rely on single hemoglobin/hematocrit measurements alone as isolated markers for bleeding severity, as they lag behind acute blood loss 3, 1
• Measure serum lactate and base deficit to estimate and monitor the extent of bleeding and tissue hypoperfusion 3, 1
• Consider near-patient coagulation testing (TEG/ROTEM) if available 1

Resuscitation Strategy

Fluid and Blood Product Administration

• Initially resuscitate with crystalloids (normal saline or balanced crystalloid) to achieve falling pulse rate, rising BP, and adequate urine output 3, 5
• Target systolic BP of 80-100 mmHg (MAP 50-60 mmHg) until major bleeding is controlled in patients without brain injury 3, 1, 5
• Transfuse packed red blood cells when hemoglobin <100 g/L in acute bleeding or when bleeding is extreme with shock 3
• For patients with cirrhosis and variceal bleeding, maintain hemoglobin target of 70-90 g/L to avoid exacerbating portal pressure 3, 5
• Avoid fluid overload, which can increase portal pressure and worsen bleeding 3

Pharmacologic Management

• Administer intravenous proton pump inhibitors immediately in non-variceal upper GI bleeding to decrease high-risk stigmata at endoscopy 2
• Consider tranexamic acid 10-15 mg/kg followed by infusion of 1-5 mg/kg/h in patients with significant ongoing bleeding 3, 1
• Administer prokinetic agents 30-60 minutes before endoscopy to improve visualization 2

Diagnostic Workup

Endoscopy Timing and Preparation

• Perform upper endoscopy within 24 hours of presentation after initial stabilization in most patients 2
• Urgent endoscopy is indicated for patients with active hematemesis, hemodynamic instability despite resuscitation, or high-risk features 3
• Endoscopy should only be performed after adequate resuscitation with stable vital signs when possible 3
• Consider endotracheal intubation before endoscopy in severely bleeding patients to prevent pulmonary aspiration 3
• Ensure endoscopy is performed by experienced endoscopists capable of therapeutic interventions 3

Additional Imaging

• Up to 8-11% of patients with hematochezia have an upper GI source, so maintain high suspicion even with lower GI symptoms 3
• Consider focused sonography (FAST) if significant free fluid or torso trauma is suspected 3
• CT imaging is reserved for hemodynamically stable patients requiring further anatomic assessment 3

Risk Stratification

High-Risk Features Requiring Intensive Monitoring

• Age >60 years with hemodynamic compromise 3
• Pulse >100 bpm, systolic BP <100 mmHg, hemoglobin <100 g/L 3
• Significant comorbid medical diseases, particularly liver disease 3
• Active hematemesis or coffee-ground emesis with shock 3
• Identify patients with liver disease early as they require specific management including restrictive transfusion strategy 3

Lower-Risk Patients

• Young patients with minor bleeding, no hemodynamic compromise, and no high-risk features may be discharged without immediate endoscopy, with outpatient follow-up arranged 3
• However, 88% of hematemesis cases stop spontaneously, and only 6% require therapeutic endoscopic intervention 6

Common Pitfalls

• Avoid delays between presentation and endoscopy in unstable patients, but never perform endoscopy before adequate resuscitation 3, 1
• Do not rely solely on blood pressure as some patients compensate well despite significant hemorrhage 4, 1
• Avoid hyperventilation and excessive PEEP in hypovolemic patients as this worsens cardiac output 3, 1
• Epinephrine injection alone is insufficient for endoscopic hemostasis and must be combined with thermal or mechanical methods 2
• Consider central venous pressure monitoring in patients with significant cardiac disease to guide fluid replacement 3