I have acute gastroenteritis and am experiencing hematemesis; what is the appropriate urgent management?

Hematemesis in Acute Gastroenteritis: Urgent Management

In a patient with acute gastroenteritis presenting with hematemesis, immediately assess hemodynamic stability using shock index (heart rate ÷ systolic blood pressure)—if shock index >1, perform CT angiography immediately and reverse any coagulopathy; if stable, proceed to urgent upper endoscopy after resuscitation, as hematemesis indicates an upper GI source requiring direct visualization rather than supportive gastroenteritis care alone. 1, 2

Immediate Hemodynamic Assessment

• Calculate shock index at presentation—a value >1 defines hemodynamic instability and mandates urgent intervention rather than routine supportive care. 1, 2
• Check for orthostatic hypotension, which indicates significant blood loss requiring ICU admission. 3
• Place at least two large-bore intravenous catheters immediately to allow rapid volume expansion. 2

Resuscitation Protocol

• Initiate aggressive intravenous crystalloid resuscitation (normal saline or Ringer's lactate) to restore blood pressure and heart rate before any diagnostic procedure. 1
• Use a restrictive transfusion strategy: maintain hemoglobin >70 g/L (7 g/dL) in patients without cardiovascular disease. 1, 3, 2
• For patients with cardiovascular disease or massive bleeding, maintain hemoglobin >80 g/L (8 g/dL), targeting ≥100 g/L. 1, 3, 2
• Correct coagulopathy immediately: transfuse fresh frozen plasma when INR >1.5 and platelets when platelet count <50 × 10⁹/µL. 1, 3

Diagnostic Pathway Based on Hemodynamic Status

Unstable Patients (Shock Index >1)

• CT angiography is the mandatory first diagnostic test—it provides the fastest, least invasive localization of bleeding with 94% sensitivity and can detect bleeding rates as low as 0.3 mL/min. 1, 2
• Following positive CTA, proceed to catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology. 1, 2
• Upper endoscopy is contraindicated in unstable patients until after CTA localization and initial stabilization. 1

Stable Patients (Shock Index ≤1)

• Perform urgent upper endoscopy (esophagogastroduodenoscopy) as the initial diagnostic procedure, as hematemesis typically indicates upper GI bleeding requiring direct visualization. 3, 2
• Upper endoscopy should be performed within 24 hours of presentation for suspected upper GI bleeding. 2

Anticoagulation/Antiplatelet Management

• If patient is on warfarin: interrupt warfarin immediately and reverse with prothrombin complex concentrate (4-factor PCC) plus low-dose vitamin K (<5 mg) for unstable hemorrhage—this is superior to fresh frozen plasma. 1, 2
• Restart warfarin at 7 days after hemostasis for patients with low thrombotic risk, or at 3 days for high thrombotic risk (e.g., mechanical mitral valve). 1
• If patient is on aspirin: permanently discontinue if used for primary prophylaxis; do not routinely stop if used for secondary prevention, but restart as soon as hemostasis is achieved if stopped. 1, 3, 2

Critical Distinction: Gastroenteritis vs. GI Bleeding

• Hematemesis is NOT a typical feature of acute gastroenteritis—viral or bacterial gastroenteritis causes nausea, vomiting, diarrhea, and abdominal pain, but not blood in vomitus. 4, 5, 6
• The presence of hematemesis indicates a separate upper GI bleeding source (peptic ulcer, esophageal varices, Mallory-Weiss tear) that requires urgent evaluation beyond supportive gastroenteritis care. 3, 2
• Approximately 10-15% of patients with severe hematochezia have an upper GI source; hematemesis makes an upper GI origin even more likely. 1

Common Pitfalls to Avoid

• Do not attribute hematemesis solely to gastroenteritis—failure to recognize a concurrent upper GI bleeding source leads to delayed diagnosis and increased mortality. 1, 2
• Do not delay resuscitation to obtain imaging in unstable patients—stabilize first with fluids and blood products, then image. 1, 3
• Do not use fresh frozen plasma as first-line reversal for warfarin—prothrombin complex concentrate is faster, does not require ABO matching, and avoids volume overload. 1
• Do not rush to endoscopy in unstable patients—this delays definitive CTA localization and potential embolization. 1

Mortality Context

• Mortality in GI bleeding is generally related to comorbidities rather than exsanguination, with overall in-hospital mortality of 3.4%, rising to 18% for inpatient-onset bleeding and 20% for patients requiring ≥4 units of red blood cells. 1, 2
• Clinical predictors of poor outcome include age >65 years, shock, comorbid illness, low hemoglobin, melena, and fresh red blood in emesis or on rectal exam. 2

When to Proceed Directly to Surgery

• If patient remains unstable despite aggressive resuscitation and successful localization, proceed directly to surgery rather than pursuing further diagnostic studies. 3, 2
• Surgery is reserved as a last resort after failure of endovascular control or when the patient continues to deteriorate despite optimal resuscitation. 1