From the Guidelines
Hematemesis workup should begin with rapid assessment of hemodynamic stability and resuscitation if needed, followed by upper endoscopy (EGD) as the cornerstone diagnostic procedure, which should be performed within 24 hours of presentation, or urgently if there is active bleeding or hemodynamic instability, as recommended by the American College of Gastroenterology practice guidelines 1. The initial evaluation includes:
- Complete blood count
- Comprehensive metabolic panel
- Coagulation studies (PT/INR, PTT)
- Type and cross-match
- BUN-to-creatinine ratio Prior to endoscopy, intravenous proton pump inhibitors (e.g., pantoprazole 80mg IV bolus followed by 8mg/hr infusion) should be initiated to reduce the risk of rebleeding and improve outcomes, as supported by the 2015 American College of Gastroenterology practice guidelines 1. Nasogastric lavage may help determine the presence of active bleeding but is not mandatory, as it may not be diagnostic in up to 16% of patients with UGIB 1. Risk stratification using scoring systems like Glasgow-Blatchford or Rockall scores helps determine the level of care needed and predict outcomes, allowing for early identification of high-risk patients who may require more aggressive management 1. Imaging studies such as CT angiography may be considered if endoscopy cannot identify the bleeding source, as it can help detect vascular malformations or other rare causes of UGIB 1. For patients with suspected variceal bleeding, terlipressin (2mg IV every 4 hours) or octreotide (50mcg IV bolus followed by 50mcg/hr infusion) should be administered, along with prophylactic antibiotics (ceftriaxone 1g IV daily), to reduce the risk of rebleeding and improve survival, as recommended by the American Association for the Study of Liver Diseases 1. The workup should also include assessment for underlying conditions such as liver disease, coagulopathy, or medication use (NSAIDs, anticoagulants) that may contribute to bleeding, as these can impact management and outcomes 1.
From the Research
Hematemesis Workup
- The workup for hematemesis typically involves an emergency endoscopy as soon as possible 2
- In patients with ulcer disease, emergency endoscopic treatment is indicated in ulcers with active bleeding or with visible vessels in the base of the ulcer 2
- The gold standard in the treatment of acute variceal bleeding is the hemostasis by endoscopic ligation or sclerotherapy 2
Pre-Endoscopy Treatment
- Pre-endoscopic use of proton pump inhibitors (PPIs) may reduce the need for endoscopic haemostatic treatment at index endoscopy 3
- A study found that the use of intravenous PPIs before an endoscopy in upper-GI bleeding reduced the need of endoscopic therapy and shortened hospital stay 4
- Another study found that infusion of high-dose omeprazole before endoscopy accelerated the resolution of signs of bleeding in ulcers and reduced the need for endoscopic therapy 5
Cost-Effectiveness
- A cost-effectiveness analysis found that preemptive use of IV PPI before an endoscopy is a cost-effective strategy in the management of UGIB 4
- The overall direct cost per patient was lower for PPI treatment compared to placebo treatment 4
Proton Pump Inhibitor Administration
- A study found that movement toward preferential use of IV push PPI prior to endoscopy for hemodynamically stable patients with confirmed or suspected UGIBs resulted in similar rates of continued bleeding or re-bleeding and generated modest cost savings 6
- The use of IV push PPI dosing may be a viable alternative to continuous infusion in hemodynamically stable patients 6