What is the workup and treatment plan for a hemodynamically stable patient with hematemesis, nausea, and a history of Non-Steroidal Anti-Inflammatory Drug (NSAID) use, after a single episode?

Management of Hematemesis in a Hemodynamically Stable Patient with NSAID Use

This patient requires immediate NSAID discontinuation, upper endoscopy within 24 hours, initiation of high-dose proton pump inhibitor therapy, and a 6-hour observation period before considering discharge. 1

Immediate Actions

Stop NSAIDs Immediately

• Discontinue all NSAID use immediately given the history of NSAID exposure and active GI bleeding. 2
• NSAIDs cause bleeding through dual mechanisms: direct mucosal injury to the GI tract and impaired platelet aggregation via COX enzyme inhibition. 2
• Patients with prior GI bleeding on NSAIDs are at highest risk for recurrent bleeding, and continuation of NSAIDs compounds this risk substantially. 2

Initial Resuscitation and Stabilization

• Establish two large-bore IV cannulae (antecubital fossae preferred) even though the patient is currently hemodynamically stable. 1
• Initiate normal saline infusion to maintain hemodynamic stability. 1
• Insert a urinary catheter and monitor hourly urine output (target >30 mL/hour). 1
• Implement continuous automated monitoring of pulse and blood pressure. 1

Diagnostic Workup

Laboratory Assessment

• Complete blood count with hemoglobin/hematocrit to assess degree of blood loss. 1
• Basic metabolic panel to evaluate electrolytes and renal function. 1
• Coagulation studies (PT/INR, PTT) to identify any underlying coagulopathy. 1
• Type and crossmatch blood products in case transfusion becomes necessary. 1

Transfusion Threshold

• Transfuse red cell concentrate if hemoglobin falls below 100 g/L (10 g/dL) or if hemodynamic instability develops despite initial fluid resuscitation. 1

Upper Endoscopy Timing

• Perform upper endoscopy within 24 hours of presentation after adequate resuscitation has been achieved. 1
• Keep the patient NPO (fasting) until hemodynamically stable to prepare for endoscopy and reduce aspiration risk. 1
• Ensure endoscopy is performed by an experienced endoscopist capable of therapeutic interventions (hemostasis if needed). 1
• For this hemodynamically stable patient with a single episode, endotracheal intubation before endoscopy is not necessary. 1

Medical Management

Proton Pump Inhibitor Therapy

• Initiate high-dose PPI therapy immediately (e.g., pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion, or equivalent oral high-dose PPI). 2
• PPIs reduce upper GI bleeding risk more effectively than H2 receptor antagonists in this setting. 2

Post-Endoscopy Care

• If endoscopy reveals peptic ulcer disease, continue PPI therapy and test for Helicobacter pylori infection. 3
• Patients who remain hemodynamically stable 4-6 hours after endoscopy can begin oral intake with a light diet. 1

Observation and Discharge Criteria

Safe Discharge Parameters (6-Hour Observation)

A hemodynamically stable patient with hematemesis can be safely discharged after 6 hours of observation if ALL of the following criteria are met: 4

• No orthostatic vital sign changes (no significant drop in BP or rise in HR with position change). 4
• Hemoglobin >10 g/dL after observation period. 4
• Age <60 years. 4
• No significant underlying comorbidities (no cardiac, hepatic, or renal disease). 4
• Patient is reliable and compliant with follow-up instructions. 4

Important caveat: This patient has nausea and NSAID use as a clear precipitant, which increases concern for ongoing ulcer disease. Even if discharge criteria are met, endoscopy should still be performed within 24 hours either as an inpatient or urgent outpatient procedure. 1

Critical Pitfalls to Avoid

NSAID-Related Considerations

• Do not substitute COX-2 selective inhibitors as an alternative—they are not safer in patients with GI bleeding history. 5
• Be aware that NSAIDs may mask ulcer symptoms before bleeding occurs; many patients present with hemorrhage as their first symptom without preceding abdominal pain. 6
• The absence of prior ulcer symptoms does not rule out significant ulcer disease in NSAID users. 6

Risk Stratification Errors

• Do not discharge without endoscopy unless the patient meets ALL five discharge criteria listed above. 4
• Even young, healthy patients can have serious underlying pathology (gastric ulcers, duodenal ulcers) requiring endoscopic evaluation. 3
• Monitor continuously for rebleeding with serial vital signs and urine output assessment. 1

Fluid Management

• If the patient develops hypoglycemia during observation, use D5NS (5% dextrose in 0.9% normal saline) for maintenance fluids rather than dextrose-free solutions. 1
• Avoid dextrose-only solutions (D5W) as they are hypotonic and inadequate for volume replacement. 1

Follow-Up Management

After Endoscopy and Discharge

• Continue PPI therapy for at least 4-8 weeks depending on endoscopic findings. 2
• Avoid all NSAIDs permanently if possible; use acetaminophen (≤3g/day) for pain management instead. 2, 5
• If H. pylori is detected, complete eradication therapy and confirm eradication. 3
• Arrange close outpatient follow-up within 1-2 weeks to reassess symptoms and ensure healing. 4