Management of Hematemesis

Initial Assessment and Resuscitation

The American College of Gastroenterology recommends immediately establishing two large-bore IV cannulae (18G or larger) in the antecubital fossae and beginning rapid fluid resuscitation with normal saline, typically 1-2 liters initially, for patients presenting with hematemesis 1, 2
The British Society of Gastroenterology suggests that if a patient remains hemodynamically unstable after initial fluid resuscitation, blood products should be administered 1, 2
Continuous monitoring of vital signs (pulse, blood pressure) using automated monitoring is recommended for patients with hematemesis 2
Assessment for shock, defined as pulse >100 beats/min and systolic BP <100 mm Hg, is crucial in the initial assessment of patients with hematemesis 2

A complete blood count (CBC) with hemoglobin and hematocrit should be ordered for patients presenting with hematemesis 2
Coagulation profile (PT/INR, PTT) and type and cross-match for blood products are essential laboratory tests for patients with hematemesis 1, 2
Serum lactate and base deficit should be measured to estimate and monitor the extent of bleeding and shock in patients with hematemesis 3

The American College of Surgeons recommends transfusing packed red blood cells when hemoglobin is less than 70-100 g/L or with active bleeding and hemodynamic instability 1, 2
A target hemoglobin level of at least 7 g/dL (4.5 mmol/L) during the resuscitation phase is recommended for patients with hematemesis 4
Maintaining mean arterial pressure >65 mmHg while avoiding fluid overload is crucial in the management of patients with hematemesis 4

The European Society of Gastrointestinal Endoscopy recommends performing upper endoscopy within 24 hours of presentation for most patients with hematemesis 1
Endoscopy should only be performed after adequate resuscitation has been achieved, and the patient should be kept fasted until hemodynamically stable 1, 2

The Rockall scoring system can be used to assess the risk of rebleeding and death in patients with hematemesis 2
High-risk features include age >80 years, shock, renal/liver failure, disseminated malignancy, and active bleeding on endoscopy 2

High-dose proton pump inhibitor therapy (80 mg IV bolus followed by 8 mg/hour infusion for 72 hours) is recommended for patients with hematemesis 5
Vasoactive drugs (terlipressin or octreotide) should be considered if portal hypertension is suspected 4
Prophylactic antibiotics should be administered if liver disease is suspected 4

Patients with liver disease require specific management protocols and should be identified early 2
Continuous observation of pulse, blood pressure, and urine output is necessary to monitor for rebleeding in patients with hematemesis 5

Delaying resuscitation while waiting for diagnostic tests can worsen outcomes in patients with hematemesis 2
Using single hematocrit measurements as an isolated marker for bleeding severity is not recommended 3
Failing to identify the source of bleeding can lead to inadequate management, as up to 15% of severe lower GI bleeding may have an upper GI source 6

Avoid nasogastric tube placement in unsedated patients due to risk of gagging, vomiting, and aerosolization; however, in ventilated patients, NGT lavage showing blood return is useful 7