Should a patient with a single episode of hematemesis and stable vital signs still go to the emergency department?

Should a Patient with a Single Episode of Hematemesis and Stable Vital Signs Go to the Emergency Department?

Yes, a patient with even a single episode of hematemesis should go to the emergency department for evaluation, regardless of stable vital signs, because hematemesis is a cardinal sign of upper gastrointestinal bleeding that requires urgent risk stratification and endoscopic assessment within 24 hours. 1

Why Immediate Emergency Evaluation Is Essential

Hematemesis Indicates Significant Upper GI Pathology

• Hematemesis is the cardinal sign of upper gastrointestinal bleeding and signals potentially serious underlying lesions including peptic ulcer disease (50-70% of cases), esophageal varices, Mallory-Weiss tears, or malignancy. 1, 2
• Approximately 25% of patients who initially stop bleeding will rebleed, and three-quarters of recurrent bleeding occurs within the first 48 hours after the initial hemorrhage. 2
• Overall mortality from upper GI bleeding ranges from 10% in non-variceal bleeding to 30% in variceal bleeding, making early identification and treatment critical. 2

Stable Vital Signs Do Not Exclude High-Risk Disease

• Hemodynamic stability at presentation does not reliably predict which patients will deteriorate or require urgent intervention. Risk stratification requires endoscopic findings, not just initial vital signs. 1
• Age >60 years, hemoglobin <100 g/L, presence of comorbidities (renal failure, liver disease, ischemic heart disease), and shock (heart rate >100 bpm and systolic BP <100 mmHg) are independent predictors of mortality and rebleeding, but these factors can only be properly assessed in the emergency department. 1
• Even young, otherwise healthy patients can have high-risk endoscopic stigmata (active bleeding, visible vessel) that require immediate therapeutic intervention. 1

What Should Happen in the Emergency Department

Immediate Resuscitation and Assessment

• Establish two large-bore IV lines and initiate crystalloid resuscitation (1-2 L normal saline or Ringer's lactate) to restore blood pressure, heart rate, and urine output >30 mL/hour. 1
• Transfuse packed red blood cells when hemoglobin falls below 80 g/L in patients without cardiovascular disease; use a higher threshold (hemoglobin <100 g/L) for patients with cardiac disease. 1
• Start high-dose intravenous proton pump inhibitor therapy immediately (pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion). 1

Risk Stratification Using Validated Scores

• Calculate the Glasgow Blatchford score (incorporating age, hemoglobin, blood urea nitrogen, systolic blood pressure, heart rate, presence of melena, syncope, and comorbidities). 1
• A Glasgow Blatchford score ≤1 identifies very low-risk patients who may be discharged for urgent outpatient endoscopy, but this requires formal emergency department evaluation and laboratory testing. 1
• A Glasgow Blatchford score >1 mandates hospital admission for inpatient endoscopy within 24 hours. 1

Endoscopy Within 24 Hours

• All patients with hematemesis should undergo upper endoscopy within 24 hours of presentation after initial hemodynamic stabilization. 1, 3
• Endoscopy successfully identifies the bleeding source in 95% of cases and provides critical prognostic information regarding rebleeding risk, need for surgery, and mortality. 3
• Endoscopic findings directly determine subsequent management: high-risk stigmata (active bleeding, visible vessel) require combination endoscopic therapy (epinephrine injection plus thermal coagulation or clipping), while low-risk stigmata (clean-based ulcer) permit early discharge. 1

Critical Pitfalls to Avoid

Do Not Rely on "Feeling Fine" After One Episode

• Approximately 65% of upper GI bleeding stops spontaneously, but 25% will rebleed and 10% will have persistent bleeding. 2
• The absence of ongoing hematemesis does not exclude high-risk lesions that will rebleed within hours to days. 2
• Conservative management without endoscopy is inappropriate because it does not allow for risk stratification and determination of appropriate disposition. 3

Do Not Delay Seeking Care

• The success rate of endoscopy is highest when performed within the first 36 hours of bleeding onset. 2
• Aggressive early diagnosis and therapy, including endoscopic hemostatic interventions, reduce mortality from hematemesis. 2
• Waiting to see if bleeding recurs before seeking care can result in life-threatening hemorrhage when the patient is no longer in a controlled medical environment. 2

Exceptions Are Extremely Rare

• Only highly selected patients with mild hematemesis, stable cardiovascular parameters, no orthostatic vital sign changes, hemoglobin >10 g/dL, age <60 years, no significant comorbidities, and reliable follow-up can potentially be discharged after 6 hours of emergency department observation. 4
• Even in these low-risk patients, urgent outpatient endoscopy within 2 weeks is mandatory because approximately 6% will have underlying malignancy. 5

Bottom Line

A single episode of hematemesis, even with stable vital signs, requires emergency department evaluation because:

1. It signals potentially life-threatening upper GI pathology that requires urgent endoscopic diagnosis and treatment 1, 2
2. 25% of patients will rebleed, most within 48 hours 2
3. Stable vital signs do not exclude high-risk lesions or predict who will deteriorate 1
4. Only formal emergency department assessment with laboratory testing and risk stratification can safely identify the rare patient who does not require immediate hospitalization 1, 4