What are the initial investigations for a patient presenting with hematemesis (vomiting blood)?

Initial Investigations for Hematemesis

Patients presenting with hematemesis require immediate assessment of hemodynamic stability, followed by urgent upper endoscopy within 24 hours after resuscitation, with laboratory testing and risk stratification guiding the timing and intensity of intervention. 1, 2

Immediate Clinical Assessment

• Check vital signs immediately to assess hemodynamic status: pulse rate, blood pressure (systolic BP <100 mmHg indicates severe bleeding), and signs of shock 1, 3
• Classify bleeding severity using pulse ≥100 beats/min, systolic BP ≤100 mmHg, and clinical signs of volume depletion to guide resuscitation intensity 1, 4
• Perform focused history to identify risk factors: liver disease/portal hypertension (suggests variceal bleeding with 30% mortality), peptic ulcer disease, antiplatelet/anticoagulant use, and prior bleeding episodes 1, 2
• Insert urinary catheter in severe cases to monitor hourly urine output (target >30 ml/h) as a marker of adequate resuscitation 1

Laboratory Investigations

Order these tests immediately upon presentation:

• Complete blood count (CBC) with hemoglobin and hematocrit, recognizing that initial values may appear falsely normal in the first 30-60 minutes after acute bleeding before plasma equilibration occurs 3
• Serial hemoglobin measurements are essential, as a single initial value is unreliable; hemoglobin <100 g/L indicates need for transfusion in acute bleeding 1, 3
• Coagulation studies: prothrombin time (PT/INR) and activated partial thromboplastin time (aPTT) to detect coagulopathy 3
• Blood urea nitrogen (BUN) and creatinine: elevated BUN/creatinine ratio suggests upper GI source 1
• Serum electrolytes for comprehensive metabolic assessment 1
• Blood type and cross-match immediately in patients with signs of severe bleeding to prepare for potential transfusion 1, 3

Critical pitfall: Do not rely on a single initial hemoglobin/hematocrit value, as it frequently appears normal despite significant ongoing bleeding because plasma equilibration requires time 3

Endoscopic Investigation

• Upper endoscopy is the primary diagnostic procedure and should be performed within 24-36 hours of presentation for optimal diagnostic yield 1, 5, 2
• Perform immediate/urgent endoscopy (after adequate resuscitation) in patients with: active hematemesis with shock, suspected variceal bleeding, or persistent hemodynamic instability despite initial resuscitation 1
• Endoscopy should only be performed once resuscitation is achieved with stable blood pressure and central venous pressure when possible 1
• In severely bleeding patients, consider endotracheal intubation before endoscopy to prevent pulmonary aspiration 1
• Endoscopy must be performed by experienced endoscopists capable of therapeutic interventions for hemostasis 1

Risk Stratification

• Patients aged >60 years with pulse >100 bpm, systolic BP <100 mmHg, and hemoglobin <100 g/L are classified as severe and require close monitoring with automated vital sign monitoring 1
• Consider central venous pressure monitoring in patients with significant cardiac disease to guide fluid replacement, though formal clinical trial evidence is lacking 1
• Identify patients with significant liver disease early, as they require specific management protocols 1

Additional Imaging (When Indicated)

• Nasogastric tube placement is NOT routinely recommended: it does not reliably aid diagnosis, does not affect outcomes, and causes complications in up to one-third of patients 1
• If upper endoscopy is negative and bleeding continues, consider that hematemesis may occasionally represent lower GI bleeding with brisk retrograde flow, requiring further investigation 1

Resuscitation Priorities

• Establish two large-bore IV cannulae in anticubital fossae for patients who are hemodynamically compromised 1
• Infuse normal saline initially (1-2 liters) to achieve falling pulse rate, rising blood pressure, and adequate urine output 1
• Transfuse red blood cells when: (1) extreme bleeding with active hematemesis and shock, or (2) hemoglobin <100 g/L in acute bleeding 1
• Administer intravenous proton pump inhibitors immediately in non-variceal bleeding to decrease probability of high-risk stigmata at endoscopy 2