What to do with a patient who presents to the ER with hematemesis and a history of recurrent N/V before her menstrual period, with all normal labs and exams?

Management of Hematemesis with Normal Labs and Exams

This patient should be reassured and discharged with instructions to return if bleeding recurs (Option B), given the self-limited nature of the bleeding, hemodynamic stability, normal investigations, and likely diagnosis of Mallory-Weiss tear related to recurrent vomiting. 1

Risk Stratification

The critical first step is determining bleeding severity using established parameters:

• Age: Mortality is rare in patients under 40 years; this patient appears young 1
• Hemodynamic status: Normal vital signs (no shock index >1, which would be pulse >100 and systolic BP <100 mmHg) 1
• Comorbidity: No mention of significant medical diseases (renal, liver, cardiac disease, or malignancy) 1
• Bleeding characteristics: Single episode of hematemesis with small amount of blood, self-limited after 4-6 hours 1
• Laboratory findings: All normal, suggesting no significant blood loss 1

Clinical Context Supporting Discharge

The history of recurrent nausea/vomiting before menstruation strongly suggests a Mallory-Weiss tear, which carries an excellent prognosis:

• Mallory-Weiss tears are associated with very low risk of rebleeding and death 1
• These lesions typically result from forceful vomiting and are self-limited 1
• Patients with minor self-terminating bleeds and no other indications for admission can be discharged for urgent outpatient investigation 1

Why Not the Other Options?

Option A (Admission for observation) is unnecessary because:

• The patient lacks high-risk features: she is young, hemodynamically stable, with normal labs 1
• Only 65% of upper GI hemorrhages require intervention; this appears self-limited 2
• Hospital resources should be reserved for patients with shock, active bleeding, or significant comorbidity 1

Option C (Urgent EGD) is not indicated because:

• Endoscopy is best undertaken on an early elective list (ideally morning after admission) for stable patients 1
• Emergency "out of hours" endoscopy is reserved for severe bleeding with hemodynamic instability 1
• In very low-risk young patients with minor bleeding and no hemodynamic compromise, it is reasonable to avoid endoscopy entirely 1
• The bleeding has already stopped for 4-6 hours, making urgent intervention unnecessary 1

Option D (Simple discharge) is incomplete without proper counseling about return precautions.

Discharge Instructions

The patient should be instructed to return immediately if she experiences:

• Recurrent hematemesis or coffee-ground vomiting 1
• Melena (black tarry stools) 1
• Lightheadedness, syncope, or palpitations suggesting hemodynamic compromise 1
• Inability to tolerate oral intake 1

If bleeding recurs, aggressive inpatient investigation is required at the first sign of a second bleed 2

Common Pitfalls to Avoid

• Do not perform nasogastric tube lavage in unsedated patients due to risk of gagging, vomiting, and potential worsening of a Mallory-Weiss tear 1
• Do not overlook the menstrual cycle association with cyclic vomiting, which may indicate hormonal triggers requiring gynecologic evaluation if symptoms persist 1
• Do not assume all hematemesis requires endoscopy; risk stratification should guide management 1