In a patient with hematemesis who has received fluids, what is the next step in management: nasogastric tube (NGT) insertion, blood products, or esophagogastroduodenoscopy (EGD)?

Management of Hematemesis After Initial Fluid Resuscitation

After initial fluid resuscitation in a patient with hematemesis, the next step is to administer blood products if hemodynamically unstable or hemoglobin <100 g/L, followed by urgent endoscopy within 24 hours—nasogastric tube insertion is not routinely recommended and should be avoided as it complicates diagnosis and treatment. 1, 2

Immediate Priorities After Fluid Resuscitation

Blood Product Administration

• Transfuse red blood cell concentrate when:

  • Active hematemesis with hemodynamic instability (pulse >100 bpm, systolic BP <100 mmHg) 1
  • Hemoglobin concentration <100 g/L in acute bleeding 1, 3
  • Extreme bleeding with shock, where O-negative blood can be given in rare circumstances, though rapid cross-matching is typically sufficient 1

• Restrictive transfusion thresholds (hemoglobin 70-80 g/L) are recommended in stable patients 2

Continued Resuscitation Monitoring

• Insert urinary catheter and monitor hourly urine output (target >30 mL/hour) 1, 3
• Continuously monitor pulse and blood pressure using automated monitoring 1, 3
• Consider central venous pressure monitoring in patients with significant cardiac disease (target CVP 5-10 cm H₂O) 1, 3
• If patient remains shocked after 1-2 liters of saline, administer plasma expanders as this indicates ≥20% blood volume loss 1, 3

Pre-Endoscopic Medical Therapy

• Administer intravenous proton pump inhibitor (PPI) therapy before endoscopy to potentially downstage the lesion and decrease probability of high-risk stigmata 2, 4
• Consider prokinetic agents 30-60 minutes before endoscopy to aid in diagnosis 4

Endoscopy Timing (The Definitive Next Step)

• Endoscopy must be performed within 24 hours of presentation for all patients with upper GI bleeding 1, 2, 3, 4

• Emergency endoscopy is indicated for:

  • Persistent hemorrhage with hemodynamic instability 1
  • Active bleeding requiring repeated transfusions 1

• Endoscopy should only be performed after adequate resuscitation is achieved 1, 3

• Keep patient fasted until hemodynamically stable 1, 3

• For severely bleeding patients, consider endotracheal intubation before endoscopy to prevent pulmonary aspiration 3

Why NOT Nasogastric Tube?

Nasogastric tube insertion should be avoided in the acute setting because:

• It complicates diagnosis and treatment in the hospital 5
• It does not change management decisions or improve outcomes 5
• Only 3-16% of patients with upper GI bleeding may have a negative nasogastric aspirate, limiting its diagnostic utility 1
• Avoid invasive procedures like NGT insertion unless other measures to relieve symptoms have failed 6

Risk Stratification to Guide Intensity of Care

Severe Bleeding (High-Risk Features)

• Age >60 years with pulse >100 bpm, systolic BP <100 mmHg, hemoglobin <100 g/L 1
• Rockall score >8 indicates high mortality risk 1, 2
• Shock index (heart rate/systolic BP) >1 indicates hemodynamic instability 2
• These patients require intensive monitoring, urinary catheter, and urgent endoscopy 1

Mild-to-Moderate Bleeding (Low-Risk Features)

• Age <60 years with normal vital signs and hemoglobin >100 g/L 1, 2
• Rockall score <3 associated with excellent prognosis 1, 2
• These patients can be managed on general medical ward with hourly vital sign monitoring and semi-elective endoscopy on next available list 1

Special Considerations

• Identify patients with significant liver disease early as they require specific management protocols 1, 3
• Bloody hematemesis plus melena indicates worse outcomes (composite endpoint 62.4% vs 25.6% for isolated hematemesis) and potentially warrants more urgent endoscopy 7
• Bloody hematemesis is associated with higher rates of hemostatic intervention (19.4%) and rebleeding (7.8%) compared to coffee-ground emesis 7

Common Pitfalls to Avoid

• Do not delay endoscopy for routine NGT placement 5
• Do not perform endoscopy before adequate resuscitation 1, 3
• Do not use vasopressors in the acute bleeding phase—focus on volume replacement 1
• Do not assume bloody hematemesis is more severe than coffee-grounds emesis—they have similar hemodynamic parameters at presentation 7