In a 14-year-old girl with irregular menstrual cycles, period‑related nausea, a single episode of hematemesis, and a soft, non‑tender abdomen, what is the most appropriate next step in management?

Appropriate Next Step: Upper Endoscopy with Biopsy

In a 14-year-old girl with irregular periods, period-related nausea, and a single episode of hematemesis (even with a soft abdomen), the most appropriate next step is urgent upper endoscopy (esophagogastroduodenoscopy) with biopsy to exclude serious upper gastrointestinal pathology, particularly peptic ulcer disease, gastroduodenal erosions, or Mallory-Weiss tear. 1

Why Endoscopy Is Essential

• Hematemesis (vomiting blood) is a red-flag symptom that mandates prompt endoscopic assessment regardless of abdominal examination findings, as patients with acute upper GI bleeding require direct visualization of the mucosa to identify the bleeding source 1

• A soft, non-tender abdomen does NOT exclude serious pathology—many patients with significant upper GI bleeding present without peritoneal signs, and the absence of abdominal tenderness cannot be used to rule out ulcers, erosions, or tears 1

• Endoscopy is the gold standard for diagnosing upper GI bleeding because it allows direct visualization, precise diagnosis, and immediate therapeutic intervention (hemostatic therapy) if active bleeding is identified 1, 2

Why the Other Options Are Inappropriate

Colonoscopy Is Wrong

• Colonoscopy evaluates the lower GI tract (colon and rectum), whereas hematemesis (vomiting blood) indicates an upper GI source above the ligament of Treitz 1
• The clinical presentation—nausea, vomiting blood—points to esophageal, gastric, or duodenal pathology, not colonic disease 1

Stool H. pylori Testing Is Premature

• While H. pylori can cause peptic ulcer disease (a common cause of upper GI bleeding accounting for 35–50% of cases), testing should follow endoscopy, not precede it 1
• Endoscopy with biopsy provides both diagnosis and the opportunity for H. pylori testing via gastric biopsy, which is more accurate than stool antigen testing in acute bleeding 1

Discharge Is Dangerous

• Hematemesis is never a "wait-and-see" symptom—it represents acute upper GI hemorrhage until proven otherwise 1
• Even a single episode of vomiting blood requires urgent evaluation because rebleeding can occur, and the initial episode may herald more severe bleeding 1
• Discharging this patient without investigation exposes her to the risk of recurrent, potentially life-threatening hemorrhage 1

Clinical Context: Adolescent Considerations

• Irregular periods and period-related nausea are common in adolescents due to anovulatory cycles and hormonal fluctuations, but these do NOT explain hematemesis 1
• The timing of nausea with menstruation may be coincidental or related to prostaglandin release, but vomiting blood is never a normal menstrual symptom 1
• Mallory-Weiss tears (15% of upper GI bleeding cases) can occur after forceful vomiting and are a plausible diagnosis in an adolescent with nausea and hematemesis 1

Diagnostic Algorithm

1. Immediate assessment: Verify hemodynamic stability (pulse, blood pressure) and check hemoglobin/hematocrit 1
2. Urgent upper endoscopy: Perform esophagogastroduodenoscopy within 24 hours to identify the bleeding source 1
3. Endoscopic findings guide management:
   • Peptic ulcer: Endoscopic hemostasis (injection, clips, thermal therapy) + proton pump inhibitor therapy 1
   • Mallory-Weiss tear: Usually self-limited; endoscopic therapy if actively bleeding 1
   • Gastroduodenal erosions: Proton pump inhibitor therapy 1
4. Biopsy for H. pylori if ulcer or gastritis is identified 1
5. Address menstrual irregularity separately after excluding GI pathology 1

Common Pitfalls to Avoid

• Never dismiss hematemesis as "just stress" or "menstrual-related"—blood in vomit always requires endoscopic evaluation 1
• Never rely on a benign abdominal exam to exclude upper GI bleeding—many patients with ulcers or erosions have minimal or no abdominal tenderness 1
• Never order colonoscopy for hematemesis—this is a fundamental error in anatomic localization 1
• Never discharge a patient with hematemesis without endoscopy—this violates the standard of care for acute upper GI bleeding 1