What is the management approach for a patient presenting with hematemesis (vomiting blood) without preceding nausea?

Management of Hematemesis Without Preceding Nausea

Hematemesis without preceding nausea requires immediate resuscitation and urgent endoscopic evaluation, as the absence of nausea does not change the fundamental approach to upper gastrointestinal bleeding management. 1

Immediate Resuscitation (First 15-30 Minutes)

Establish two large-bore IV lines (18-gauge or larger) in the antecubital fossae and begin rapid fluid resuscitation with 1-2 liters of normal saline immediately. 1

• Continuously monitor vital signs using automated monitoring for pulse and blood pressure 1
• Assess for shock: pulse >100 beats/min and systolic BP <100 mmHg indicates hemodynamic instability 1
• If the patient remains unstable after initial crystalloid resuscitation, immediately administer blood products 1
• Maintain mean arterial pressure >65 mmHg while avoiding fluid overload 1

STAT Laboratory Tests

Order the following immediately upon presentation:

• Complete blood count with hemoglobin and hematocrit 1
• Coagulation profile (PT/INR, PTT) 1
• Type and cross-match for blood products 1
• Serum lactate and base deficit to estimate extent of bleeding and shock 1

Blood Transfusion Thresholds

Transfuse packed red blood cells when hemoglobin is <70-100 g/L or with active bleeding and hemodynamic instability. 1

• Target hemoglobin of at least 7 g/dL (4.5 mmol/L) during resuscitation 1
• Do not rely on single hematocrit measurements as isolated markers for bleeding severity—this is a common pitfall 1

Pharmacological Management

Initiate high-dose proton pump inhibitor therapy: 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours. 1

• Consider vasoactive drugs (terlipressin or octreotide) if portal hypertension or liver disease is suspected 1
• Administer prophylactic antibiotics if liver disease is present 1
• Use scheduled antiemetics (ondansetron 8 mg IV every 4-6 hours) to prevent further vomiting episodes that could worsen bleeding 2

Risk Stratification

Apply the Rockall scoring system to assess rebleeding and mortality risk:

• High-risk features include: age >80 years, shock, renal/liver failure, disseminated malignancy, and active bleeding on endoscopy 1
• Identify patients with liver disease early, as they require specific management protocols 1

Endoscopy Timing

Perform upper endoscopy within 24 hours of presentation for most patients, but only after adequate resuscitation has been achieved. 1

• Keep the patient fasted until hemodynamically stable 1
• Endoscopy within the first 36 hours has the highest success rate for diagnosis and therapeutic intervention 3
• In hemodynamically stable patients without active bleeding, further assessment with CT may be appropriate before endoscopy 1

Critical Pitfalls to Avoid

• Never delay resuscitation while waiting for diagnostic tests—this worsens outcomes 1
• Do not assume lower GI source without upper endoscopy, as up to 15% of severe lower GI bleeding originates from upper GI sources 1
• Avoid nasogastric tube placement in unsedated patients due to risk of gagging, vomiting, and aerosolization; however, in ventilated patients, NGT lavage showing blood return is useful 4
• Do not perform endoscopy before adequate resuscitation—hemodynamic stability takes priority 1

Special Considerations

The absence of preceding nausea is clinically notable but does not alter management priorities. Hematemesis without nausea may suggest:

• More acute arterial bleeding (less time for nausea to develop) 3
• Variceal bleeding (which can present abruptly without warning symptoms) 1
• Gastric diverticulum or other structural lesions 5

Regardless of the presence or absence of nausea, mortality from hematemesis approaches 10% overall and 30% for variceal bleeding, making aggressive early management essential. 3