What is the recommended referral procedure for a patient presenting with hematemesis (vomiting blood)?

Hematemesis Referral and Management

Immediate Hospital Referral is Mandatory

All patients presenting with hematemesis require immediate hospital referral for urgent evaluation and management, as mortality rates approach 10% overall and up to 30% in variceal bleeding, with early specialist intervention significantly reducing mortality. 1, 2, 3

---

Why Hospital Admission is Non-Negotiable

• Mortality risk is substantial: Hospital-based studies demonstrate 10% overall mortality, rising to 30% with variceal sources, making outpatient management inappropriate for initial presentation 2, 3
• Early intervention saves lives: Specialist evaluation within 24 hours reduces mortality compared to delayed treatment 1
• Unpredictable clinical course: 25% of patients rebleed after initial cessation, with 75% of recurrent bleeding occurring within 48 hours 2
• Immediate diagnostic and therapeutic capabilities are essential: Hospital admission enables hemodynamic monitoring, IV resuscitation, blood transfusion, and urgent endoscopy with therapeutic intervention 1

---

Pre-Hospital and Emergency Department Management

Initial Stabilization During Transport

• Establish two large-bore IV lines (18-gauge or larger in antecubital fossae) and begin aggressive normal saline resuscitation immediately 1, 4
• Assess hemodynamic status: Check pulse (>100 bpm indicates severity), blood pressure (<100 mmHg systolic indicates instability), and calculate estimated blood loss 1
• Rapid transport to nearest hospital takes absolute priority over diagnostic procedures in moderate-to-severe bleeding 2
• Avoid measures that complicate hospital diagnosis and treatment during transport 2

Fluid Resuscitation Protocol

• Infuse 1-2 liters of normal saline initially in hemodynamically compromised patients 1, 4
• Add plasma expanders if shock persists after 2 liters, indicating ≥20% blood volume loss 1, 4
• Insert urinary catheter and monitor hourly urine output (target >30 mL/hour indicates adequate resuscitation) 1
• Consider central venous pressure monitoring in patients with significant cardiac disease (target CVP 5-10 cm H₂O) 1, 4

Blood Transfusion Criteria

• Transfuse when hemoglobin <7 g/dL in most patients 1
• Transfuse when hemoglobin <9 g/dL in patients with massive bleeding or cardiovascular comorbidities 1, 5
• Transfuse immediately when active hematemesis with shock is present 1

---

Risk Stratification for Referral Urgency

High-Risk Features Requiring Emergency Referral

• Hemodynamic instability: Pulse >100 bpm, systolic BP <100 mmHg, orthostatic changes 1, 6
• Active hematemesis (fresh red blood) versus coffee ground emesis 5
• Age >60 years: Significantly higher mortality requiring aggressive management 1, 5
• Significant comorbidities: Cardiovascular disease, renal failure, liver disease/cirrhosis 1, 5
• Hemoglobin <10 g/dL at presentation 6

Lower-Risk Features (Still Require Hospital Evaluation)

• Very select young patients (<60 years) with minor bleeding, no hemodynamic compromise, hemoglobin >10 g/dL, no orthostatic changes, no significant comorbidities, and reliable follow-up may be considered for discharge after 6-hour observation and appropriate evaluation 1, 6
• However, this represents a minority of cases and requires careful clinical judgment 6

---

Hospital-Based Diagnostic Approach

Endoscopy Timing

• Perform endoscopy within 24 hours of presentation for most patients after achieving hemodynamic stability 1, 4
• Critical error to avoid: Never perform endoscopy before adequate resuscitation—this increases mortality 1
• Keep patient fasted until hemodynamically stable 1, 4
• Endoscopy success rate is highest when performed within first 36 hours of bleeding onset 2

Endoscopy Preparation

• Ensure experienced endoscopist capable of therapeutic interventions for ulcers and varices 1, 4
• Consider endotracheal intubation before endoscopy in severely bleeding patients to prevent pulmonary aspiration 1, 4
• Full resuscitation equipment must be available 1

---

Common Etiologies to Anticipate

• Peptic ulcer disease: 35-50% of cases (leading nonvariceal cause) 5
• Esophageal varices: 5-10% overall but cause 66-70% of massive hematemesis cases 5, 7
• Mallory-Weiss tears: ~15% of cases, typically from forceful vomiting 5
• Gastroduodenal erosions: 8-15% of cases, commonly NSAID-associated 5
• Esophagitis: 5-15% of cases, more common with coffee ground emesis 5

---

Special Populations Requiring Heightened Vigilance

Cirrhotic Patients

• Identify early: Require specialized management protocols with significantly higher mortality 8, 4
• Variceal bleeding mortality approaches 30% versus 10% for nonvariceal sources 2
• Rebleeding rate is 19.4% in variceal versus 6.1% in nonvariceal bleeding 7
• Consider early TIPS placement in Child-Pugh class C (score 10-13) or class B with active bleeding despite vasoactive agents 8

Elderly Patients

• Age >65 years independently predicts mortality and requires more aggressive management 1, 5
• Higher rates of comorbidities compound risk 3

---

Critical Pitfalls to Avoid

• Never delay hospital referral for hematemesis—outpatient management of initial presentation is inappropriate 1, 2
• Do not perform endoscopy before adequate resuscitation—this is a critical error increasing mortality 1
• Do not underestimate coffee ground emesis—still requires full evaluation with endoscopy within 24 hours 5
• Recognize that 10% of patients have persistent bleeding and 25% rebleed after initial cessation 2
• Avoid hyperventilation during resuscitation—associated with increased mortality in hemorrhagic shock 8