From the Guidelines
Hematemesis workup should begin with rapid assessment of hemodynamic stability and resuscitation if needed, followed by upper endoscopy (EGD) within 24 hours, or urgently if active bleeding is suspected, as recommended by the most recent guidelines 1.
Initial Evaluation
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, as this has been shown to improve outcomes in patients with upper gastrointestinal bleeding 1.
Diagnostic Procedures
- Upper endoscopy (EGD) is the cornerstone diagnostic procedure
- Video capsule endoscopy (VCE) may be considered in certain cases, but EGD is generally preferred
- Imaging studies such as CT angiography may be considered if endoscopy is non-diagnostic or contraindicated
Risk Stratification and Management
Risk stratification using scoring systems like Glasgow-Blatchford can guide management decisions, and patients with suspected variceal bleeding should receive octreotide (50mcg IV bolus followed by 50mcg/hr infusion) and prophylactic antibiotics (ceftriaxone 1g IV daily) 1.
Underlying Causes
The workup should also include assessment for underlying causes including:
- Peptic ulcer disease
- Varices
- Mallory-Weiss tears
- Gastritis
- Malignancy as identifying the etiology guides specific treatment approaches and prevents recurrence, with a mortality rate of 10% for acute upper gastrointestinal bleeding 1.
From the Research
Hematemesis Workup
- The initial evaluation of a patient with suspected upper gastrointestinal bleeding, including hematemesis, begins with assessment of hemodynamic status, identification of potential risk factors, and appropriate triage of level of care 2.
- Endoscopic evaluation can be performed to diagnose and potentially treat the source of bleeding, with risk factors that increase the propensity for recurrent bleeding identified and addressed 2.
- Proton pump inhibitors (PPIs) are commonly used in the management of upper gastrointestinal bleeding, with studies suggesting that high-dose PPI infusion is not inferior to second-look endoscopy with bolus PPI in preventing peptic ulcer rebleeding 3.
- Pre-emptive use of intravenous PPI before endoscopy has been shown to be a cost-effective strategy in the management of upper gastrointestinal bleeding, reducing the need for endoscopic therapy and shortening hospital stay 4.
- The use of PPIs in the management of gastroesophageal varices is more limited, with evidence suggesting that short-course PPI use post-endoscopic variceal ligation may reduce ulcer size, but high-dose infusion and prolonged use are not supported by current evidence 5.
- Pharmacist-managed protocols for reducing continuous infusion PPI use and substituting with intravenous push dosing have been shown to be effective in reducing costs and maintaining similar rates of continued bleeding or re-bleeding 6.