What is the most appropriate management plan for a patient with stable vital signs, presenting with hematemesis after episodes of excessive vomiting, and normal lab results?

Management of Hematemesis After Excessive Vomiting with Stable Vital Signs

Upper GI endoscopy within 24 hours is the most appropriate management for this patient with hematemesis following excessive vomiting, given their hemodynamically stable presentation. 1

Clinical Context and Likely Diagnosis

This presentation is highly suggestive of a Mallory-Weiss tear—a mucosal laceration at the gastroesophageal junction caused by forceful vomiting. 1 The patient's stable vital signs (BP 112/63, HR 89, RR 21, SpO2 96%) and normal hemoglobin (135 g/L) indicate they are not actively exsanguinating and have not lost significant blood volume. 1

Why Upper GI Endoscopy is the Correct Answer

Diagnostic and Prognostic Value

• Endoscopy successfully identifies the bleeding source in 95% of cases and provides critical prognostic information regarding rebleeding risk, need for surgery, and mortality. 1
• Endoscopic findings directly determine risk stratification: Mallory-Weiss tears and clean-based ulcers carry very low rebleeding and mortality risk, while active arterial bleeding carries up to 80% risk of continued bleeding or death. 1

Timing Considerations

• Endoscopy within 24 hours of admission is the standard of care for patients with upper GI bleeding once hemodynamic stability is achieved. 1, 2
• This patient is already hemodynamically stable, making them an ideal candidate for early elective endoscopy (ideally the morning after admission). 1
• Emergency "out of hours" endoscopy is reserved for patients with persistent hemorrhage causing hemodynamic instability or requiring repeated transfusions—neither of which applies here. 1

Therapeutic Capability

• Endoscopy allows immediate therapeutic intervention if high-risk stigmata are identified, which decreases transfusion requirements, reduces rebleeding rates, and shortens hospital stays. 1

Why the Other Options Are Incorrect

B. Conservative Treatment (Incorrect)

• While approximately 75-80% of upper GI bleeding stops spontaneously 1, conservative management without endoscopy is inappropriate because:
  • You cannot risk-stratify the patient without visualizing the bleeding source. 1
  • Endoscopic findings are essential for determining disposition, level of monitoring needed, and duration of hospitalization. 1
  • Even low-risk patients benefit from endoscopic confirmation to safely facilitate early discharge. 3

C. Exploratory Laparotomy (Incorrect)

• Surgery is reserved for patients who fail endoscopic hemostasis or have continued bleeding despite therapeutic endoscopy. 1
• This hemodynamically stable patient has not yet undergone endoscopy, making surgical exploration premature and unnecessarily invasive. 1

D. Sengstaken-Blakemore Tube (Incorrect)

• This device is specifically designed for variceal bleeding from portal hypertension, not nonvariceal upper GI bleeding. 1
• The clinical scenario describes post-emetic hematemesis (suggesting Mallory-Weiss tear or mucosal injury), not variceal hemorrhage. 1
• Inappropriate use of balloon tamponade in nonvariceal bleeding can cause esophageal perforation and other serious complications. 1

Initial Management Steps Before Endoscopy

While awaiting endoscopy, appropriate supportive care includes:

• Establish two large-bore IV cannulae for potential volume resuscitation. 4, 2
• Initiate IV proton pump inhibitor therapy upon presentation, though this does not replace the need for endoscopy. 4
• Keep the patient NPO until endoscopy is performed. 2
• Monitor vital signs continuously for any signs of clinical deterioration. 4, 2

Critical Pitfall to Avoid

Do not delay endoscopy beyond 24 hours in patients with significant bleeding once stabilized, as this increases resource utilization, transfusion requirements, and hospital length of stay without improving outcomes. 1, 2 This patient should undergo endoscopy on the next available elective list, ideally within 12-24 hours. 4, 2