Management of Hematemesis After Initial Fluid Resuscitation

Immediate Priorities After Fluid Resuscitation

The American College of Gastroenterology recommends transfusing red blood cell concentrate in patients with active hematemesis and hemodynamic instability, or hemoglobin concentration <100 g/L in acute bleeding 1, 2
The American College of Gastroenterology recommends restrictive transfusion thresholds (hemoglobin 70-80 g/L) in stable patients 3
Insertion of a urinary catheter and monitoring of hourly urine output (target >30 mL/hour) is recommended 1, 4
Continuous monitoring of pulse and blood pressure using automated monitoring is recommended 1, 4
Consider central venous pressure monitoring in patients with significant cardiac disease (target CVP 5-10 cm H₂O) 1, 4
Administration of plasma expanders is recommended if patient remains shocked after 1-2 liters of saline, indicating ≥20% blood volume loss 1, 4

Administer intravenous proton pump inhibitor (PPI) therapy before endoscopy to potentially downstage the lesion and decrease probability of high-risk stigmata 3, 5

Endoscopy must be performed within 24 hours of presentation for all patients with upper GI bleeding, according to the American College of Radiology 5, 3, 4
Emergency endoscopy is indicated for patients with persistent hemorrhage and hemodynamic instability, or active bleeding requiring repeated transfusions 5
Endoscopy should only be performed after adequate resuscitation is achieved, as recommended by the American College of Gastroenterology 1, 4
Keep patient fasted until hemodynamically stable 1, 4
Consider endotracheal intubation before endoscopy to prevent pulmonary aspiration in severely bleeding patients 4

Patients with severe bleeding (high-risk features) require intensive monitoring, urinary catheter, and urgent endoscopy, according to the American College of Gastroenterology 1, 2
Patients with mild-to-moderate bleeding (low-risk features) can be managed on general medical ward with hourly vital sign monitoring and semi-elective endoscopy on next available list 1, 2, 3

Identify patients with significant liver disease early, as they require specific management protocols, according to the American Association for the Study of Liver Diseases 1, 4
Avoid using vasopressors in the acute bleeding phase, and focus on volume replacement, as recommended by the American Society of Anesthesiologists 7, 8