What is the appropriate management for a patient with a history of alcoholism presenting with haemetemesis?

History of Present Illness for Hematemesis in an Alcoholic Patient

A comprehensive HPI for hematemesis in an alcoholic patient must prioritize identifying variceal versus non-variceal bleeding sources, assessing hemodynamic stability, and documenting alcohol use patterns to guide immediate resuscitation and endoscopic management. 1, 2

Essential Components of the History

Bleeding Characteristics

• Document the precise timing, color, consistency, frequency, and duration of hematemesis to estimate severity and acuity 1
• Distinguish between fresh red blood (indicating active bleeding), coffee-ground emesis (suggesting slower bleeding with gastric acid exposure), or melena (indicating upper GI source) 3
• Quantify the volume of hematemesis (e.g., "vomited approximately 500 mL of bright red blood twice in the past 2 hours") 1
• Ask about preceding forceful vomiting episodes, which may suggest Mallory-Weiss tear rather than variceal bleeding 2, 4

Alcohol Use History

• Document heavy drinking pattern: duration (>6 months), quantity (>40 g/day, approximately 3-4 standard drinks), and timing of last drink 5
• Record years of alcohol abuse, as chronic use coupled with cirrhosis is additive for bleeding risk 6
• Assess for recent binge drinking or withdrawal symptoms, as acute intoxication can cause hemorrhagic gastritis 4

Hemodynamic Assessment

• Record vital signs at presentation: pulse rate, blood pressure (including orthostatic changes), and mental status 5, 1
• Shock is defined as pulse >100 bpm AND systolic BP <100 mmHg, indicating massive bleeding requiring immediate intervention 5, 2
• Document postural changes (>20 mmHg drop in systolic BP or >20 bpm increase in pulse) indicating significant volume loss 5, 3

Stigmata of Chronic Liver Disease

• Ask about and document jaundice onset within 8 weeks of last drinking period, as this indicates decompensation with 40-50% mortality without treatment 5
• Inquire about prior episodes of ascites, confusion/encephalopathy, or known cirrhosis diagnosis 5
• Document history of prior variceal bleeding or banding procedures 5, 3

Comorbidities and Risk Factors

• Age >60 years, particularly >80 years, dramatically increases mortality risk to approximately 30% in patients >90 years 5, 1
• Document cardiovascular disease (coronary artery disease, heart failure, arrhythmias), as these patients require higher hemoglobin transfusion thresholds 1
• Record chronic kidney disease, particularly in elderly patients, as this increases bleeding risk 1
• Ask about history of malignancy, especially gastric or esophageal cancer 1

Medication History

• Document ALL anticoagulants with exact dosing and timing of last dose: warfarin, rivaroxaban, apixaban, dabigatran 1
• Record antiplatelet agents including over-the-counter aspirin, clopidogrel, prasugrel, ticagrelor 1
• Ask about NSAIDs, which potentiate gastric mucosal injury when combined with alcohol 4
• Document recent antibiotic use (particularly amoxicillin-clavulanate), which can cause gastric irritation 1

Sample HPI Template

"[Age]-year-old [male/female] with [X years] history of heavy alcohol use ([X drinks/day]) presents with [number] episodes of [fresh red blood/coffee-ground] hematemesis totaling approximately [volume] over [time period]. Last drink was [timing]. Patient reports [presence/absence] of preceding forceful vomiting. Associated symptoms include [melena/dizziness/syncope/abdominal pain]. Known history of [cirrhosis/prior variceal bleeding/none]. Vital signs: BP [X/X] mmHg, HR [X] bpm, with [presence/absence] of orthostatic changes. Patient takes [anticoagulants/antiplatelets/none]. Comorbidities include [cardiovascular disease/CKD/malignancy]. Jaundice [present/absent] for [duration]."

Critical Pitfalls to Avoid

• Never assume all upper GI bleeding in alcoholics is variceal—approximately 20-30% are from non-variceal sources (peptic ulcer, Mallory-Weiss tear, hemorrhagic gastritis) 3
• Do not delay documentation of transfusion requirements, as clinically significant bleeding is defined as requiring ≥2 units within 24 hours 5, 3
• Avoid underestimating bleeding severity in patients without shock, as 75-80% of upper GI bleeding stops spontaneously but still requires risk stratification 2
• Document presence of SIRS criteria on admission, as this predicts multi-organ failure with very high mortality 5