Emergency Room Management of Hematemesis

DEFINITION & THERAPEUTIC GOALS

• Definition: Bleeding from site proximal to ligament of Treitz.
• Presentation: Hematemesis (bright red or coffee-ground), melena, or hematochezia (in massive hemorrhage).
• Therapeutic Goals: Resuscitation, volume/blood replacement, platelet/coagulation factor correction, bleeding source identification/control, recurrent bleeding prevention.

INITIAL ASSESSMENT & STABILIZATION

• Prioritize hemodynamic stabilization over diagnostic evaluation.
• Apply REO mnemonic: Resuscitate, Evaluate, Operate.

Resuscitation Protocol

• Airway/Breathing: Maintain patent airway; support breathing; provide oxygen supplementation if required.
• Venous Access: Insert two large-bore IV cannulas.
• Monitoring: Initiate continuous charting of vital signs, pulse pressure, and urine output; assess for shock or orthostatic changes.
• Gastric Decompression: Insert nasogastric tube (NGT) to clear stomach, estimate bleeding severity, and monitor ongoing hemorrhage.
• Fluid Replacement: Administer rapid IV infusion of isotonic crystalloids (normal saline or Ringer lactate); 20 ml/kg bolus if shock present.
• Blood Transfusion: Transfuse packed red blood cells (PRBC) to maintain hemoglobin between 7–9 g/dL. Avoid over-transfusion to prevent portal pressure rebound.
• Coagulopathy Correction: Administer Vitamin K, fresh frozen plasma (FFP), or platelets as clinically indicated.

PHARMACOTHERAPY

Initiate empiric medical therapy concurrently with fluid resuscitation.

Drug Class	Agent & Dosing	Mechanism & Indications
Acid Suppression	IV Pantoprazole: 2 mg/kg (max 80 mg) loading dose, followed by 0.2 mg/kg/hr infusion.	Promotes clot stability; raises intragastric pH; indicated for suspected non-variceal bleeds (peptic ulcer, gastritis).
Vasoactive Agents	IV Octreotide: 1 μg/kg bolus followed by 1.0–5.0 μg/kg/hr continuous infusion.	Decreases splanchnic blood flow and portal pressure; indicated for suspected variceal hemorrhage.
Antibiotics	3rd-generation cephalosporin for 7 days.	Prophylaxis against bacterial infection in cirrhotic patients with variceal bleed; significantly reduces mortality.

DIAGNOSTIC & THERAPEUTIC ENDOSCOPY

• Timing: Perform Esophagogastroduodenoscopy (EGD) within 12-24 hours post-hemodynamic stabilization. Contraindicated in hemodynamically unstable patients.
• Variceal Bleeding Interventions:
  • Endoscopic variceal ligation (EVL) (preferred modality).
  • Endoscopic sclerotherapy (EST) using 1% ethoxysclerol.
  • Tissue adhesive glue (N-butyl-2-cyanoacrylate or isobutyl-2-cyanoacrylate) for gastric varices.
• Non-Variceal Bleeding Interventions:
  • Mechanical devices (hemostatic clipping, banding).
  • Injection therapy (diluted epinephrine 1:100,000).
  • Thermal therapy (heater probe, bipolar electrocoagulation, argon plasma coagulation).

MANAGEMENT OF REFRACTORY BLEEDING

• Balloon Tamponade: Sengstaken-Blakemore or Minnesota tube placement for maximum 12 hours. Temporizing measure for uncontrolled variceal bleeding prior to definitive therapy.
• Interventional Radiology: Transjugular intrahepatic portosystemic shunt (TIPS) for refractory variceal bleeding or massive gastric varices. Angiographic embolization (microcoil, cyanoacrylate) for brisk non-variceal bleeding.
• Surgical Intervention: Portocaval shunt, esophageal staple transection/devascularization, or exploratory laparotomy indicated if endoscopic and medical management fail.

DIFFERENTIAL DIAGNOSIS OF UGI BLEEDING

Age Group	Common Etiologies
Newborn/Infant	Swallowed maternal blood, Vitamin K deficiency, reflux esophagitis, stress ulcer, hemorrhagic disease of newborn, vascular malformation.
Preschool (2-5 yr)	Vomiting-induced tear (Mallory-Weiss), acid-peptic disease, esophageal varices, caustic ingestion, foreign body impaction.
Older Child/Adolescent	Esophageal varices, peptic ulcer disease, Mallory-Weiss tear, hemorrhagic gastritis, Dieulafoy lesion.