Management of Recurrent Hematemesis

Initial Evaluation and Stabilization

The American College of Physicians recommends immediate evaluation and adequate resuscitation as critical for the appropriate management of patients with hematemesis, including stabilizing blood pressure and restoring intravascular volume before diagnostic and therapeutic procedures 1
In patients with acute variceal hemorrhage, a restrictive red blood cell transfusion strategy is recommended, aiming to maintain a hemoglobin level of 7-9 g/dL, according to the American Association for the Study of Liver Diseases 2
The placement of a nasogastric tube may be considered in selected patients, as the presence of blood in the aspirate has prognostic value, as suggested by the American College of Gastroenterology 1

The administration of a prokinetic agent (erythromycin) before endoscopy is recommended to improve visualization and reduce the need for a second endoscopy, as suggested by the World Gastroenterology Organisation 3
Angiography should be considered as a second-line investigation after a negative endoscopy, according to the European Society of Gastrointestinal Endoscopy 3
Computed tomography with contrast before colonoscopy can increase the detection rate of vascular lesions in cases of lower gastrointestinal bleeding, as recommended by the American College of Radiology 5

If variceal hemorrhage is suspected, vasoactive agents should be started as soon as possible after admission, according to the American Association for the Study of Liver Diseases 2
Proton pump inhibitor (PPI) therapy should be initiated as soon as possible after diagnosis, as recommended by the American College of Gastroenterology 4
For bleeding ulcers, high-dose PPI therapy is recommended, with a bolus of 80mg followed by a continuous infusion of 8mg/hour for 72 hours, as suggested by the European Helicobacter Study Group 4
Short-term antibiotic prophylaxis should be implemented in patients with acute variceal hemorrhage, according to the American Association for the Study of Liver Diseases 2

Endoscopic treatment should be performed in patients with acute variceal hemorrhage, as recommended by the American Association for the Study of Liver Diseases 2
In bleeding ulcers, mechanical endoscopic therapy alone or in combination with injection is more effective than injection alone, as suggested by the European Society of Gastrointestinal Endoscopy 3

If bleeding control fails despite combined pharmacological and endoscopic therapy, a transjugular intrahepatic portosystemic shunt (TIPS) should be considered as a rescue treatment, according to the American Association for the Study of Liver Diseases 2
In patients with refractory bleeding from peptic ulcers, surgical intervention with open surgery is suggested, as recommended by the European Society of Emergency Surgery 6
Balloon tamponade may be considered as a bridge therapy for patients who do not achieve hemostasis after endoscopic treatment, but should not exceed 24 hours due to its complications, as suggested by the American College of Gastroenterology 2
Angioembolization may be considered in hemodynamically stable patients where endoscopic hemostasis fails twice or is not possible/feasible, according to the European Society of Emergency Surgery 3

The combination of endoscopic variceal ligation (EVL) and non-selective beta-blockers (NSBBs) is suggested as primary treatment to prevent variceal rebleeding, according to the American Association for the Study of Liver Diseases 2
Repeated EVL every 2-8 weeks is recommended until variceal eradication is achieved, as suggested by the American Association for the Study of Liver Diseases 2
PPIs are recommended for 6-8 weeks after endoscopic treatment of bleeding peptic ulcers to allow mucosal healing, according to the European Helicobacter Study Group 3
Testing for H. pylori should be performed in all patients with gastric ulcers and eradication should be confirmed after completing treatment, as recommended by the American College of Gastroenterology 4

Massive and potentially life-threatening bleeding is uncommon in patients with inflammatory bowel disease (IBD), occurring in less than 6% of cases, according to the European Crohn's and Colitis Organisation 5
In ulcerative colitis, bleeding typically occurs in patients with pancolitis due to diffuse areas of mucosal ulceration, while in Crohn's disease, bleeding is usually the result of focal erosion into an intestinal vessel, as suggested by the European Crohn's and Colitis Organisation 5