What is the management for a 20-year-old woman with Gastroesophageal Reflux Disease (GERD) who presents with a single episode of hematemesis (vomiting blood) with a small volume?

Management of Single Episode Small-Volume Hematemesis in a 20-Year-Old Woman with GERD

For a young woman with known GERD presenting with one small-volume hematemesis episode, perform upper endoscopy within 24 hours after ensuring hemodynamic stability, as this represents the standard diagnostic and therapeutic approach for upper GI bleeding regardless of volume. 1, 2

Initial Assessment and Stabilization

Immediate hemodynamic evaluation is the first priority:

• Calculate shock index (heart rate ÷ systolic blood pressure) immediately—a value >1 indicates instability requiring urgent intervention 2, 3
• Establish two large-bore IV cannulae in the antecubital fossae for venous access 2
• Initiate normal saline resuscitation (1-2 liters initially) to achieve hemodynamic stability 2
• Monitor vital signs continuously with automated monitoring 2

Key clinical predictors suggesting higher risk despite small volume include:

• Age >65 years (not applicable here), shock, comorbid illness, low hemoglobin, fresh red blood in emesis, or melena 3
• In this young patient with a single small-volume episode, risk is likely low, but endoscopy remains indicated 1, 2

Blood Work and Risk Stratification

Obtain essential laboratory tests:

• Complete blood count to assess hemoglobin level 3
• Coagulation studies (PT/INR) 3
• Blood type and cross-match if hemodynamically unstable 3

Transfusion is indicated only if:

• Hemoglobin <7 g/dL in patients without cardiovascular disease 3
• Hemoglobin <8 g/dL in patients with cardiovascular disease 3
• Active bleeding with hemodynamic instability 2

Endoscopic Evaluation

Upper endoscopy (EGD) should be performed within 24 hours after adequate resuscitation: 1, 2

• Endoscopy successfully identifies the bleeding source in 95% of cases 1
• Keep the patient fasted until hemodynamically stable 2
• Endoscopy should be performed by experienced endoscopists capable of therapeutic interventions 2

Common pitfall to avoid: Even though this is a single small-volume episode in a young patient, do not discharge without endoscopy unless the patient is very low-risk (young, minor bleeding, no hemodynamic compromise, and no concerning features). 2 In this case, the presence of hematemesis warrants endoscopic evaluation to identify the source and assess for high-risk stigmata.

Likely Findings in GERD-Related Hematemesis

Potential endoscopic findings include:

• Esophagitis with erosions or ulceration 4
• Mallory-Weiss tear (common with vomiting) 1
• Gastric erosions 1
• Rarely, PPI-induced fundic gland polyps if on long-term PPI therapy 5

Medical Management

Initiate or optimize PPI therapy:

• Omeprazole 20 mg once daily before meals for symptomatic GERD 6
• For erosive esophagitis, continue for 4-8 weeks 6
• PPIs are the most effective treatment for GERD and reduce risk of complications 4

Important caveat: While PPIs are first-line therapy, long-term use (years) is associated with increased risk of fundic gland polyps, which can rarely cause hematemesis themselves. 5 However, this should not deter appropriate short-term use for acute management.

Post-Endoscopy Monitoring

If hemodynamically stable 4-6 hours after endoscopy:

• Allow oral intake with light diet 2
• Continue monitoring pulse, blood pressure, and urine output for signs of rebleeding 2

Repeat endoscopy is indicated if:

• Clinical evidence of active rebleeding (fresh hematemesis, melena, hemodynamic instability) 1
• Concerns about suboptimal initial endoscopic therapy 1

When to Consider Alternative Diagnoses

Be alert for red flags suggesting non-GERD causes:

• Forceful or projectile vomiting suggests other pathology requiring upper GI series 7
• Multiple presentations with inconsistent findings should raise concern for factitious disorder 8
• Presence of warning signs like choking, gagging, or severe irritability warrants broader investigation 7