What is the appropriate assessment and management for a patient presenting with haematemesis?

Assessment and Management of Haematemesis

All patients presenting with haematemesis require immediate risk stratification using the Rockall scoring system (age, shock, comorbidity, endoscopic findings) to categorize mortality risk, followed by early endoscopy within 24 hours for most patients, with emergency endoscopy reserved only for those in haemorrhagic shock. 1

Initial Assessment and Risk Stratification

Immediately categorize patients into high or low risk of death using these independent risk factors: 1

High-Risk Features (requiring intensive monitoring):

• Age >60 years (mortality risk increases to 30% in patients >90 years) 1
• Shock: pulse >100 bpm AND systolic BP <100 mmHg 1
• Haemoglobin <100 g/L 1
• Significant comorbidity: advanced renal disease, liver disease, disseminated cancer, cardiac/respiratory/CNS disease 1

Low-Risk Features (can be fast-tracked):

• Age <40 years (deaths are rare) 1
• No shock (systolic BP >100, pulse <100) 1
• No significant comorbid disease 1

Immediate Resuscitation

Vascular Access and Fluid Management:

• Insert two large-bore IV cannulae in anticubital fossae for haemodynamically compromised patients 1
• Infuse normal saline initially to achieve falling pulse rate, rising BP, and adequate urine output (>30 ml/h) 1
• Most patients require 1-2 litres of saline; if shock persists after this, plasma expanders are needed as ≥20% blood volume has been lost 1

Blood Transfusion Indications:

• Extreme bleeding with active haematemesis and shock 1
• Haemoglobin <100 g/L in acute bleeding (changes in cardiac output occur at this level) 1
• Target haemoglobin 70-90 g/L if transfusion is necessary 1

Monitoring Requirements:

• Insert urinary catheter and measure hourly volumes in severe cases 1
• Continuous automated pulse and BP monitoring 1
• Consider central venous pressure monitoring in patients with significant cardiac disease (target CVP 5-10 cm H₂O) 1

Endoscopy Timing and Setting

Timing Strategy:

• Most patients can be safely endoscoped on an early elective list (ideally the morning after admission) 1
• Emergency "out of hours" endoscopy is needed only for a minority with severe ongoing bleeding 1
• Endoscopy should only be performed after resuscitation is achieved 1
• Highest success rate when performed within first 36 hours of bleeding onset 2

Location and Personnel:

• Fully equipped endoscopy unit with trained nurses is preferred 1
• Operating theatre with anaesthetic cover may be safer for emergency out-of-hours cases 1
• Consider endotracheal intubation in severely bleeding patients to prevent pulmonary aspiration 1
• Experienced endoscopists skilled in therapeutic procedures must perform the examination 1

Endoscopic Findings and Prognosis

Very Low Risk (consider early discharge):

• Normal upper GI endoscopy 1
• Mallory-Weiss tear 1
• Ulcer with clean base 1

High Risk (50-80% rebleeding/death risk):

• Active bleeding from peptic ulcer in shocked patient: 80% risk 1
• Non-bleeding visible vessel: 50% risk of rebleeding 1

Management by Patient Category

Young, Healthy Patients with Minor Bleeding:

• Fast-track towards discharge after endoscopy if low-risk findings 1
• Can be discharged after 6-hour observation if: no orthostatic changes, no significant comorbidity, Hb >10 g/dL, age <60 years, reliable and compliant 3

Elderly with Multiple Comorbidities and Severe Bleeding:

• Manage in high dependency unit 1
• Close monitoring with continuous vital signs 1
• Identify and manage liver disease specifically as these patients require different protocols 1

Critical Pitfalls to Avoid

• Do not perform endoscopy on general wards for severely bleeding patients—they need high-intensity support unavailable on wards 1
• Do not delay endoscopy excessively, but also do not endoscope before adequate resuscitation 1
• Do not rely solely on haemoglobin at presentation—it may not reflect acute blood loss initially 1
• Do not miss liver disease—these patients require specific management protocols 1

Documentation Requirements

• Formal standardized endoscopy report must be issued 1
• Clearly document prognostic factors (age, shock, comorbidity, endoscopic findings) 1
• Accurately describe therapeutic interventions (endoscopic, surgical, pharmacological) 1

Protocol Implementation

Every institution must have a distributed protocol for upper GI haemorrhage management accessible to all medical and nursing staff in medical, geriatric, surgical wards, admission units, laboratories, and pharmacy 1