What is the best approach for evaluating and treating a patient with hematemesis, considering their demographic and medical history, including previous gastrointestinal bleeding, liver disease, or anticoagulant use?

Evaluation and Management of Hematemesis

Immediately assess hemodynamic stability using shock index (heart rate/systolic BP), and if >1 or patient is unstable, initiate aggressive resuscitation with two large-bore IVs, 1-2 liters crystalloid, and proceed directly to urgent upper endoscopy once stabilized—never before achieving hemodynamic stability. 1, 2

Initial Assessment and Risk Stratification

Hemodynamic Evaluation

• Calculate shock index immediately (heart rate divided by systolic BP); a value >1 indicates hemodynamic instability requiring aggressive intervention 1
• Classify patients as severe bleeding if: age >60 years, pulse >100 bpm, systolic BP <100 mmHg, or hemoglobin <100 g/L 1
• Mild-moderate bleeding patients have normal vital signs, hemoglobin >100 g/L, age <60 years, and minimal comorbidity 1

Critical History Elements

• Time of last anticoagulant dose and whether patient takes warfarin, DOACs, or antiplatelet agents 1
• History of liver disease is crucial as these patients require specific management protocols distinct from non-cirrhotic bleeding 1
• Previous GI bleeding episodes, peptic ulcer disease, or portal hypertension increase likelihood of upper GI source 1
• Document presence of significant cardiac disease as this affects transfusion thresholds and monitoring requirements 1

Immediate Resuscitation (First 30 Minutes)

Vascular Access and Fluid Management

• Establish two large-bore peripheral IV cannulae in the anticubital fossae for rapid volume replacement 1, 2
• Infuse 1-2 liters of normal saline immediately to restore hemodynamic stability in compromised patients 1, 2
• Use restrictive fluid strategy after initial resuscitation to avoid over-expansion, which exacerbates portal pressure, impairs clot formation, and increases rebleeding risk 2
• Target urine output >30 mL/hour and mean arterial pressure >65 mmHg as markers of adequate resuscitation 1, 2

Monitoring Requirements

• Insert urinary catheter in severe cases and measure hourly urine volumes 1, 2
• Monitor pulse and blood pressure continuously using automated systems 1, 2
• Consider central venous pressure monitoring in patients with significant cardiac disease to guide fluid replacement, though this lacks formal trial evidence 1

Pharmacologic Interventions (Within First Hour)

Immediate Drug Therapy

• Start octreotide immediately upon suspicion of upper GI bleeding, even before endoscopy: 50 mcg IV bolus (can repeat if ongoing bleeding), followed by continuous infusion at 50 mcg/hour for 2-5 days 2
• Administer high-dose IV proton pump inhibitor upon presentation, though optimal timing and duration are not definitively established 2
• Give ceftriaxone 1g IV every 24 hours (maximum 7 days) to reduce infections, rebleeding, and mortality in patients with GI bleeding 2

Anticoagulation Management

• Interrupt warfarin therapy immediately at presentation 1
• In unstable GI hemorrhage with warfarin, reverse anticoagulation with prothrombin complex concentrate and vitamin K 1
• Avoid routine correction of coagulation parameters unless there is documented bleeding diathesis, as this may worsen outcomes 2
• For patients on DOACs with major bleeding, consider specific reversal agents (idarucizumab for dabigatran; andexanet alfa for apixaban/rivaroxaban) 1

Blood Transfusion Strategy

Transfusion Thresholds

• Transfuse red blood cells when hemoglobin <100 g/L in patients presenting with acute bleeding, as cardiac output changes occur at this threshold 1
• Use restrictive transfusion thresholds (Hb trigger 70 g/L, target 70-90 g/L) in clinically stable patients without cardiovascular disease 1
• For patients with cardiovascular disease, use trigger of 80 g/L and target of 100 g/L 1
• Do not transfuse to hemoglobin >90 g/L unless patient has active cardiac ischemia, as liberal transfusion increases mortality 2
• In extreme bleeding with shock, O-negative blood can be given, though rapid cross-matching usually makes this unnecessary 1

Endoscopic Evaluation

Timing and Preparation

• Perform endoscopy within 12-24 hours of presentation once circulatory and respiratory stability is achieved 2, 3
• Never perform endoscopy before achieving hemodynamic stability, as this increases procedural risk 1, 2
• In mild-moderate bleeding, endoscopy can be performed on the next available list after overnight observation 1
• Severely bleeding patients may require endoscopy with endotracheal intubation in place to prevent pulmonary aspiration 1
• Endoscopy should only be performed by experienced endoscopists capable of therapeutic hemostasis procedures 1

Alternative Investigations

• If upper endoscopy is negative and bleeding continues, consider that 15-20% of presumed lower GI bleeds originate from upper GI sources 1
• CT angiography may be indicated if patient remains unstable after initial resuscitation and source is unclear 1

Level of Care and Disposition

Admission Criteria

• Admit to ICU or high-acuity monitored setting for all patients with acute variceal or significant upper GI hemorrhage 2
• Severe bleeding patients require close monitoring with continuous automated vital signs, urinary catheter, and frequent reassessment 1
• Mild-moderate bleeding patients can be admitted to general medical ward with hourly vital signs and urine output monitoring 1

Discharge Considerations

• Very low-risk young patients (<60 years) with minor bleeding, no hemodynamic compromise, hemoglobin >100 g/L, no significant comorbidity, and reliable follow-up can be discharged without endoscopy 1, 4
• If endoscopy shows no stigmata of recent hemorrhage, varices, or cancer, prognosis is excellent and early discharge is appropriate 1

Critical Pitfalls to Avoid

• Do not administer excessive crystalloid volumes causing fluid overload, as this worsens portal hypertension, impairs coagulation, and increases rebleeding risk 2
• Do not delay endoscopy beyond 24 hours in patients with significant bleeding once stabilized 2, 3
• Do not routinely correct INR or platelet counts without evidence of ongoing bleeding despite endoscopic therapy 2
• Do not miss liver disease as these patients require fundamentally different management protocols 1
• Do not assume portal hypertension in all variceal bleeding—rare causes like SVC obstruction ("downhill varices") can mimic portal hypertension but require different treatment 5