Initial Investigations for Hematemesis

Immediate Clinical Assessment

The American College of Gastroenterology recommends checking vital signs immediately to assess hemodynamic status, including pulse rate, blood pressure, and signs of shock in patients with hematemesis 1, 2
The European Society of Gastrointestinal Endoscopy suggests classifying bleeding severity using pulse ≥100 beats/min, systolic BP ≤100 mmHg, and clinical signs of volume depletion to guide resuscitation intensity 1
A focused history should be performed to identify risk factors, such as liver disease/portal hypertension, peptic ulcer disease, antiplatelet/anticoagulant use, and prior bleeding episodes, with a mortality rate of 30% for variceal bleeding 1
Insertion of a urinary catheter is recommended in severe cases to monitor hourly urine output, with a target of >30 ml/h, as a marker of adequate resuscitation 1

The British Society of Gastroenterology recommends ordering a complete blood count (CBC) with hemoglobin and hematocrit immediately upon presentation, recognizing that initial values may appear falsely normal in the first 30-60 minutes after acute bleeding 2
Serial hemoglobin measurements are essential, as a single initial value is unreliable, with hemoglobin <100 g/L indicating the need for transfusion in acute bleeding 1, 2
Coagulation studies, including prothrombin time (PT/INR) and activated partial thromboplastin time (aPTT), should be performed to detect coagulopathy 2
Blood urea nitrogen (BUN) and creatinine levels should be measured, with an elevated BUN/creatinine ratio suggesting an upper GI source 1
Serum electrolytes should be assessed for comprehensive metabolic evaluation 3
Blood type and cross-match should be performed immediately in patients with signs of severe bleeding to prepare for potential transfusion 3, 2

The American Society for Gastrointestinal Endoscopy recommends that upper endoscopy be performed within 24-36 hours of presentation for optimal diagnostic yield 1
Immediate/urgent endoscopy should be performed in patients with active hematemesis with shock, suspected variceal bleeding, or persistent hemodynamic instability despite initial resuscitation 1
Endoscopy should only be performed once resuscitation is achieved with stable blood pressure and central venous pressure when possible 1
In severely bleeding patients, consideration should be given to endotracheal intubation before endoscopy to prevent pulmonary aspiration 1
Endoscopy must be performed by experienced endoscopists capable of therapeutic interventions for hemostasis 1

Patients aged >60 years with pulse >100 bpm, systolic BP <100 mmHg, and hemoglobin <100 g/L are classified as severe and require close monitoring with automated vital sign monitoring 1
Central venous pressure monitoring should be considered in patients with significant cardiac disease to guide fluid replacement, although formal clinical trial evidence is lacking 1
Patients with significant liver disease should be identified early, as they require specific management protocols 1

The European Society of Gastrointestinal Endoscopy recommends that nasogastric tube placement is not routinely recommended, as it does not reliably aid diagnosis, does not affect outcomes, and causes complications in up to one-third of patients 4
If upper endoscopy is negative and bleeding continues, consideration should be given to the possibility that hematemesis may occasionally represent lower GI bleeding with brisk retrograde flow, requiring further investigation 4

The American College of Surgeons recommends establishing two large-bore IV cannulae in anticubital fossae for patients who are hemodynamically compromised 1
Normal saline should be infused initially (1-2 liters) to achieve falling pulse rate, rising blood pressure, and adequate urine output 1
Red blood cells should be transfused when there is extreme bleeding with active hematemesis and shock, or when hemoglobin <100 g/L in acute bleeding 1

Evaluate airway patency immediately by checking for pooling of oral secretions or vomitus, irregular respirations, and any signs of obstruction. 5

Identify shock in children by systolic blood pressure < 80 mm Hg (or < 70 mm Hg in infants < 1 year), tachycardia, cool extremities, and capillary‑refill time ≥ 3 seconds. 5

Provide rapid stabilization for children presenting with active seizures or any degree of depressed consciousness, as these conditions require urgent supportive measures. 5

Perform endotracheal intubation before endoscopic evaluation in children with markedly altered consciousness (Glasgow Coma Scale < 8) or visible pooling of secretions to prevent aspiration. 5

Begin resuscitation with isotonic crystalloid (normal saline) using 20 mL/kg boluses, repeated as needed up to a total of 1–2 L in children, aiming for a decreasing pulse rate, rising blood pressure, and urine output >30 mL/h. 6