What is the best course of action for a patient with abdominal pain and hematemesis (vomiting blood)?

Management of Abdominal Pain with Hematemesis

This patient requires immediate hemodynamic resuscitation with crystalloid fluids, blood transfusion to maintain hemoglobin 7-9 g/dL if needed, and urgent upper endoscopy within 24 hours once hemodynamically stable to identify and treat the bleeding source. 1

Immediate Assessment and Resuscitation

Hemodynamic stabilization takes absolute priority:

• Rapidly infuse normal saline or lactated Ringer's solution to correct hypovolemia and maintain blood pressure 2
• Transfuse packed red blood cells when hemoglobin falls below 7 g/dL, targeting a post-transfusion hemoglobin of 7-9 g/dL using a restrictive strategy that has demonstrated improved survival 1, 2
• Avoid excessive crystalloid administration, as over-expansion can exacerbate portal pressure, impair clot formation, and increase rebleeding risk 1

Initial laboratory workup must include:

• Complete blood count to assess hemoglobin and platelet levels 3, 2
• Basic metabolic panel including blood urea nitrogen and creatinine 3
• Coagulation panel (PT/INR, PTT) 2
• Liver function tests 2
• Blood type and crossmatch for potential transfusion 3, 2

Risk Stratification

Severity classification depends on:

• Presence of tachycardia (heart rate >100 bpm indicates significant blood loss) 1
• Hemoglobin level (values <10 g/dL suggest moderate to severe bleeding) 1
• Patient age (>60 years increases risk) 1
• Vital sign abnormalities including orthostatic hypotension or frank hypotension 3, 2

Diagnostic Approach

Upper endoscopy is the definitive diagnostic and therapeutic intervention:

• Perform within 24 hours of presentation once hemodynamic stability is achieved 1, 2
• Endoscopy identifies the bleeding source, establishes prognosis based on endoscopic findings, and allows immediate therapeutic intervention 1
• Do not delay endoscopy beyond 24 hours in patients with significant bleeding once stabilized 1

Physical examination should specifically assess for:

• Signs of hemodynamic compromise (pallor, tachycardia, hypotension, altered mental status) 3, 2
• Abdominal tenderness or peritoneal signs that might indicate perforation or other complications 3
• Digital rectal examination to confirm blood in stool and exclude anorectal pathology 3

Medical Management

Proton pump inhibitor therapy:

• Initiate high-dose PPI immediately upon presentation with upper GI bleeding 2
• Continue high-dose PPI for the first 72 hours post-endoscopy, as this is when rebleeding risk is highest 2

Coagulopathy correction:

• Reverse anticoagulation with fresh frozen plasma and vitamin K if INR >1.5 3
• Transfuse platelets if platelet count <50,000/µL 3

Critical Pitfalls to Avoid

Common errors that worsen outcomes:

• Delaying endoscopy beyond 24 hours in hemodynamically stable patients with significant bleeding 1
• Over-resuscitation with excessive crystalloid volumes leading to increased portal pressure and rebleeding 1
• Failing to obtain blood type and crossmatch early in patients with signs of severe bleeding 3
• Inadequate monitoring during the initial 72-hour high-risk period for rebleeding 2

Special Considerations

Historical factors that guide differential diagnosis:

• NSAID use increases risk of peptic ulcer disease 2
• History of liver disease or cirrhosis suggests possible variceal bleeding 2
• Previous hepatopancreatobiliary procedures (even years prior) raise concern for hemobilia from pseudoaneurysm 4
• Recent abdominal surgery may indicate anastomotic complications 5

If endoscopic hemostasis fails:

• Attempt transcatheter arterial embolization as the next step 2
• Proceed to surgery only if embolization fails to achieve hemostasis 2