What is the management approach for haematemesis (vomiting blood)?

Management of Haematemesis

Haematemesis requires immediate resuscitation with airway protection, large-bore IV access, high-flow oxygen, and early endoscopy within 24-36 hours while simultaneously correcting coagulopathy and initiating tranexamic acid if massive bleeding is present. 1, 2

Immediate Resuscitation Actions

Airway and Breathing

• Secure the airway immediately in patients with decreased consciousness or ongoing massive haematemesis to prevent aspiration 1
• Administer high-flow oxygen (high FiO2) to all patients 1

Vascular Access and Initial Assessment

• Establish large-bore IV access (ideally 8-Fr central venous catheter in adults; if unsuccessful, consider intraosseous or surgical venous access) 1
• If the patient is conscious, talking, and has a palpable peripheral pulse, blood pressure is adequate—avoid delaying resuscitation for formal BP measurement 1
• Obtain baseline blood work immediately: full blood count, PT, aPTT, Clauss fibrinogen (not derived fibrinogen), and cross-match 1
• Consider near-patient viscoelastic testing (TEG or ROTEM) if available 1

Fluid Resuscitation Strategy

• Resuscitate with warmed blood products, not crystalloids, in patients with massive haemorrhage 1
• Blood availability hierarchy: Group O (fastest) → group-specific → cross-matched 1
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 1

Coagulation Management

Tranexamic Acid

• Administer tranexamic acid 1g IV over 10 minutes as soon as possible if the patient is bleeding or at risk of significant bleeding, followed by 1g infusion over 8 hours 1
• Must be given within 3 hours of bleeding onset for maximum benefit 1

Coagulopathy Correction

• For fibrinogen <1 g/L: administer fibrinogen concentrate 3-4g or cryoprecipitate (15-20 single donor units) 1
• Target fibrinogen level >1.5 g/L in massive haemorrhage 1
• For PT/aPTT >1.5 times normal: administer fresh frozen plasma at minimum 1:2 ratio with packed red blood cells 1
• Maintain platelet count >50 × 10⁹/L (>100 × 10⁹/L if traumatic brain injury present) 1
• Monitor and correct ionised calcium to normal range during massive transfusion 1

Diagnostic Approach

Endoscopy Timing

• Perform endoscopy within 24-36 hours of presentation for optimal diagnostic yield and therapeutic intervention 2
• Earlier endoscopy may be indicated if active bleeding continues or patient deteriorates 2
• Endoscopy achieves 85% diagnostic rate and allows for hemostatic interventions 3

Risk Stratification

Key predictors of poor outcome requiring intensive monitoring: 4

• Active bleeding visualized at endoscopy (strongest predictor)
• Presentation with haematemesis plus melena (worse outcomes than isolated haematemesis) 5
• Encephalopathy present
• Age >50 years 3
• Transfusion requirement ≥4 units 3
• Platelet count <100 × 10⁹/L 4
• Elevated urea 4

Blood Pressure Management

Important caveat: Restore organ perfusion but do not aggressively normalize blood pressure until bleeding is controlled 1

• Once bleeding is controlled, then aggressively normalize blood pressure, acid-base status, and temperature 1
• Avoid vasopressors during active bleeding phase 1

Definitive Management

Source Control

• Endoscopic hemostatic intervention is first-line for variceal bleeding (sclerotherapy, banding) and non-variceal sources (injection, clips, thermal therapy) 2, 6
• Consider angioembolization if endoscopic therapy fails 6
• Surgery reserved for failure of endoscopic and radiological interventions 6

Post-Resuscitation Care

• Admit to critical care unit for continued monitoring after bleeding control 1
• Monitor coagulation parameters, hemoglobin, blood gases, and assess for rebleeding 1
• Initiate venous thromboprophylaxis as soon as bleeding is controlled (patients rapidly develop prothrombotic state) 1

Common Pitfalls

• Do not assume "coffee-grounds" emesis is less severe: bloody versus coffee-grounds hematemesis show similar severity at presentation and mortality rates (6.6% vs 9.3%) 5
• Do not use derived fibrinogen levels—they are misleading; use Clauss fibrinogen only 1
• Do not delay tranexamic acid waiting for laboratory confirmation—administer based on clinical suspicion 1
• 75% of rebleeding occurs within 48 hours of initial hemorrhage, requiring intensive early monitoring 2
• Variceal bleeding carries 30% mortality versus 10% for non-variceal upper GI bleeding 2