What is the diagnosis and management of hematemesis?

Differential Diagnosis and Management of Hematemesis

Hematemesis requires immediate assessment of hemodynamic stability, followed by urgent upper endoscopy within 12-24 hours after resuscitation, with the primary goal of identifying the bleeding source and achieving hemostasis to reduce mortality and rebleeding risk. 1

Initial Assessment and Resuscitation

Hemodynamic Evaluation

• Assess circulatory status immediately using shock index (heart rate divided by systolic blood pressure; unstable if >1) 1
• Establish two large-bore peripheral IV lines or central venous access for fluid resuscitation with crystalloid or colloid 1
• Monitor vital signs continuously: blood pressure, heart rate, and oxygen saturation 1

Airway Protection

• Tracheal intubation is indicated for active hematemesis, inability to maintain or protect airway, or when optimal sedation is needed for endoscopic examination 1
• Insert nasogastric tube to protect airway and decompress the stomach in unstable patients 1

Laboratory Assessment

• Obtain hemoglobin, complete blood count, coagulation parameters (PT/INR, platelet count), and type and cross-match 1
• Measure blood lactate as a sensitive marker of bleeding severity and tissue hypoperfusion; base deficit is an acceptable alternative 1

Blood Product Management

Transfusion Strategy

• Use restrictive transfusion thresholds: transfuse at hemoglobin <7 g/dL with target 7-9 g/dL 1
• For patients with cardiovascular disease, use hemoglobin trigger of 8 g/dL with target of 10 g/dL 1
• Restrictive transfusion is associated with decreased mortality and reduced rebleeding rates 1

Coagulation Management

• Avoid routine correction of coagulopathy unless life-threatening bleeding; overuse of blood products increases portal venous thrombosis risk 1
• No specific INR or platelet cutoff reliably predicts procedural bleeding risk 1
• For unstable hemorrhage on warfarin, reverse with prothrombin complex concentrate and vitamin K 1
• For life-threatening bleeding on direct oral anticoagulants, consider idarucizumab or andexanet 1

Pharmacologic Therapy

Vasoactive Drugs (for suspected variceal bleeding)

• Initiate octreotide immediately: 50 mcg IV bolus (can repeat in first hour if ongoing bleeding), followed by continuous infusion of 50 mcg/hour for 2-5 days 1
• Vasoactive drug administration reduces mortality and transfusion requirements 1
• Somatostatin analogs inhibit gastric acid secretion; proton pump inhibitors are not required with octreotide 1

Antibiotic Prophylaxis (for cirrhotic patients)

• Administer ceftriaxone 1 g IV every 24 hours (maximum 7 days) 1
• Prophylactic antibiotics reduce infections, rebleeding, and mortality in variceal bleeding 1

Proton Pump Inhibitors (for non-variceal bleeding)

• Administer IV proton pump inhibitors in acute setting to decrease probability of high-risk stigmata at endoscopy 2

Diagnostic Approach

Endoscopy Timing and Preparation

• Perform urgent upper endoscopy within 12 hours of presentation after circulatory and respiratory stabilization 1
• Consider erythromycin 250 mg IV 30-120 minutes before endoscopy to optimize visualization (check QT interval first) 1
• Prokinetic agents may be given 30-60 minutes before endoscopy to aid diagnosis 2

Distinguishing Upper vs. Lower GI Source

• Hematemesis (bloody or coffee-grounds) indicates upper GI source above the ligament of Treitz 2
• In stable patients, perform gastroscopy to rule out upper GI bleeding 1
• Bloody hematemesis and coffee-grounds emesis have similar severity at presentation (similar pulse, blood pressure, hemoglobin levels), though bloody emesis has modestly higher rates of hemostatic intervention and rebleeding 3
• Hematemesis plus melena indicates worse outcomes than isolated hematemesis, with composite adverse events occurring in 60% vs. 26% of cases 3

Common Etiologies and Their Management

Variceal Bleeding

• Gastric varices: Endoscopic cyanoacrylate injection (ECI) is first-line therapy for cardiofundal varices 1
• Esophageal varices: Endoscopic band ligation is preferred 1
• For refractory bleeding: TIPS with direct embolization or balloon-occluded retrograde transvenous obliteration (BRTO) 1
• BRTO has less rebleeding and encephalopathy compared to TIPS for cardiofundal varices 1

Non-Variceal Bleeding

• Peptic ulcer disease, gastritis, Mallory-Weiss tears, malignancy 2
• Endoscopic hemostatic techniques: injection (epinephrine must be combined with another method), thermal, or mechanical 2
• Bleeding stops spontaneously in 88% of cases; only 6% require therapeutic endoscopic intervention 4

Inflammatory Bowel Disease

• In ulcerative colitis: bleeding typically from diffuse mucosal ulceration in pancolitis 1
• In Crohn's disease: focal erosion into intestinal vessel; may involve small bowel 1
• Consider CT angiography before colonoscopy to improve detection of vascular lesions 1

Antiplatelet and Anticoagulant Management

Aspirin

• For secondary prevention: do not stop aspirin; if stopped, restart as soon as hemostasis is achieved 1
• For primary prophylaxis: permanently discontinue 1

Dual Antiplatelet Therapy

• Do not routinely stop in patients with coronary stents; manage in liaison with cardiology 1
• In unstable hemorrhage: continue aspirin if P2Y12 inhibitor is interrupted 1
• Reinstate P2Y12 inhibitor within 5 days due to high thrombosis risk 1

Anticoagulants

• Interrupt warfarin and direct oral anticoagulants at presentation 1
• For low thrombotic risk: restart warfarin at 7 days; restart DOACs at maximum 7 days 1
• For high thrombotic risk (prosthetic metal heart valve, recent VTE <3 months): consider low molecular weight heparin at 48 hours 1

Interventional Radiology and Surgery

Angiography

• Consider for stable patients when endoscopy fails or is not feasible 1
• Requires active bleeding >0.5 mL/min for localization 1
• CT angiography is more sensitive (detects bleeding at 0.3 mL/min) and should be performed first 1
• Super-selective embolization achieves immediate hemostasis in 40-100% with 15% rebleeding rate 1
• Risk of bowel ischemia is 1-4% 1

Surgical Intervention

• Reserved for massive, life-threatening bleeding unresponsive to endoscopic or angiographic therapy 1
• Decision depends on bleeding source, hemodynamic status, and availability of less invasive options 1
• Surgical intervention for hematemesis is exceedingly rare in modern practice 4

Critical Pitfalls to Avoid

• Do not delay endoscopy beyond 24 hours in hemodynamically stable patients; optimal timing is within 12 hours 1
• Avoid liberal transfusion strategies; overtransfusion increases portal pressure and rebleeding risk 1
• Never use epinephrine injection alone for endoscopic hemostasis; always combine with thermal or mechanical method 2
• Do not routinely correct coagulopathy in cirrhotic patients; this increases thrombotic complications without proven benefit 1
• Do not stop antiplatelet therapy in patients with recent coronary stents without cardiology consultation 1