What are the interventions for a patient with hematemesis and melena?

Management of Hematemesis and Melena

Immediately establish two large-bore IV lines in the anticubital fossae and begin aggressive fluid resuscitation with normal saline while simultaneously assessing hemodynamic stability—this takes absolute priority before any diagnostic procedures. 1

Initial Resuscitation and Stabilization

Hemodynamic Assessment

• Check pulse, blood pressure, and calculate estimated blood loss to categorize severity: patients with pulse >100 bpm, systolic BP <100 mmHg, and hemoglobin <100 g/L represent severe bleeding requiring intensive monitoring 1
• Insert a urinary catheter and measure hourly urine output (target >30 ml/h indicates adequate resuscitation) 1
• Consider central venous pressure monitoring in patients with significant cardiac disease to guide fluid replacement (target CVP 5-10 cm H₂O) 1

Fluid and Blood Product Management

• Infuse 1-2 liters of normal saline initially in hemodynamically compromised patients 1
• If shock persists after 2 liters, add plasma expanders as this indicates ≥20% blood volume loss 1
• Transfuse red blood cells when:
  • Hemoglobin <100 g/L in acute bleeding (or maintain >7 g/dL, or >9 g/dL with massive bleeding/cardiovascular comorbidities) 1, 2
  • Active hematemesis with shock is present 1
  • O-negative blood is reserved only for extreme circumstances as rapid cross-matching is typically available 1

Risk Stratification

High-Risk Features Requiring Aggressive Management

• Age >60-65 years 1, 2
• Significant comorbidities (cardiac, renal, or liver disease) 1, 2
• Hematemesis (indicates worse outcomes than melena alone, with 19% five-day rebleeding rate vs 10.6%, and 8.4% mortality vs 2.8%) 3
• Hemodynamic instability despite resuscitation 1

Identify Liver Disease Early

• Specifically assess for cirrhosis as these patients require specialized management and have significantly higher mortality 1
• Esophageal varices cause 5-10% of upper GI bleeding overall but account for 66-70% of massive hematemesis cases 4

Endoscopic Evaluation and Therapy

Timing and Preparation

• Perform endoscopy only after achieving hemodynamic stability—blood pressure and CVP should ideally be stable, though this may not be possible in active bleeding 1
• In hemodynamically stable patients, perform endoscopy within 24 hours of admission 4, 2
• Keep patient fasted until hemodynamically stable 1

Procedural Considerations

• Endoscopy should be performed by experienced endoscopists capable of therapeutic interventions for ulcers and varices 1
• In severely bleeding patients, consider endotracheal intubation before endoscopy to prevent pulmonary aspiration 1
• Most endoscopy can be done semi-electively in the endoscopy unit, but facilities must be available for urgent procedures with full resuscitation equipment 1

Therapeutic Interventions

• Provide endoscopic hemostasis for high-risk stigmata: active bleeding, non-bleeding visible vessel, or adherent clot 5
• Modalities include mechanical, thermal, injection, or combination therapy based on bleeding etiology and endoscopist experience 5

Post-Endoscopy Management

Pharmacologic Therapy

• Initiate high-dose proton pump inhibitor therapy following successful endoscopic treatment of ulcer bleeding 2
• Address underlying causes: Helicobacter pylori eradication, acid suppression, and counsel regarding NSAID use 1

Monitoring for Rebleeding

• Rebleeding is defined as: fresh hematemesis/melena with shock, CVP fall >5 mmHg, or hemoglobin reduction >20 g/L over 24 hours 4
• Consider repeat colonoscopy with hemostasis if rebleeding occurs 5

Special Populations and Pitfalls

Common Pitfalls to Avoid

• Do not perform endoscopy before adequate resuscitation—this is a critical error that increases mortality 1
• Do not assume black stools are melena without confirming sticky, tar-like consistency and characteristic odor 2
• Hematochezia with hemodynamic instability may indicate upper GI bleeding (not lower GI) and warrants upper endoscopy first 4, 5

Cardiovascular Considerations

• Patients with established high-risk cardiovascular disease should not stop aspirin (secondary prophylaxis) during lower GI bleeding—timing of resumption depends on bleeding severity and thromboembolic risk 5
• Avoid NSAIDs in patients with history of GI bleeding, particularly from diverticulosis or angioectasia 5

Low-Risk Exception

• Very low-risk young patients with minor bleeding, no hemodynamic compromise, and no high-risk features may be discharged without endoscopy after appropriate evaluation 1