Why it matters
Hematemesis in the ED is always a red flag, but when the patient is cirrhotic, assume variceal bleed until proven otherwise. These patients can crash quickly with hypovolemic shock, aspiration, and death. Early recognition and protocolized management save lives.
1) The 30-second story
- Known cirrhosis or stigmata of chronic liver disease.
- Hematemesis or coffee-ground vomit, sometimes melena.
- Hypotension, tachycardia, diaphoresis.
- May present confused (hepatic encephalopathy).
2) Quick differential
- Variceal bleed (esophageal, gastric) – most dangerous.
- Peptic ulcer disease.
- Mallory–Weiss tear (esp. with retching).
- Erosive gastritis.
- Malignancy.
3) Red flags 🚨
- Hemodynamic instability (SBP <90, HR >120).
- Altered mental status (encephalopathy, shock).
- Massive hematemesis (>500 mL or continuous).
- Known varices/previous banding.
- INR >1.5, platelet count <50k (coagulopathy).
- Jaundice, ascites (advanced liver disease).
4) Bedside exam & first steps
- Airway: protect against aspiration — these patients vomit liters of blood.
- Breathing: O₂ as needed.
- Circulation: 2 large-bore IVs, fluids, blood products ready.
- Look for stigmata of cirrhosis: spider nevi, ascites, caput medusae.
- Assess volume status: cap refill, MAP, urine output.
5) Investigations
- CBC: Hb (but remember acute loss may not show immediately).
- Coagulation panel, INR, fibrinogen, platelets.
- BMP/LFTs: renal and liver function.
- Type and cross: prepare for transfusion.
- CXR: check for aspiration.
- ECG, troponin: if chest pain/ischemia suspected.
6) Management in the ED
- Resuscitation
- Protect airway (intubate early if massive hematemesis or encephalopathy).
- 2 large-bore IVs; transfuse blood products.
- Restrictive transfusion: target Hb 7–8 g/dL (avoid over-transfusion which ↑ portal pressure).
- Correct coagulopathy (platelets, FFP, cryoprecipitate as indicated).
- Specific therapy
- Octreotide IV bolus 50 mcg, then infusion 50 mcg/hr.
- Prophylactic antibiotics: ceftriaxone 1 g IV daily (reduces mortality).
- PPI infusion (omeprazole/pantoprazole) — covers peptic ulcer until scope clarifies.
- Consults
- GI for urgent endoscopy/banding.
- ICU for unstable patients.
- Surgery/interventional radiology if refractory (TIPS, balloon tamponade as bridge).
7) Disposition
- All cirrhotic hematemesis patients need admission.
- ICU if unstable, high transfusion requirement, airway at risk.
- Admit stable patients to monitored bed with GI availability.
Rookie pearls
- Airway early — don’t wait until patient is drowning in blood.
- Octreotide + antibiotics should be started in the ED, before endoscopy.
- Restrictive transfusion strategy saves lives in variceal bleeding.
- If patient collapses during vomiting, think massive bleed + aspiration.
- Mallory–Weiss is common, but cirrhotic + hematemesis = varices until proven otherwise.
Common pitfalls
- Waiting for Hb to drop before transfusing — it lags behind clinical loss.
- Forgetting antibiotics — mortality benefit is real.
- Over-resuscitation → increases portal pressure → worsens bleeding.
- Delaying octreotide until after GI arrives.
- Not protecting the airway in encephalopathic or vomiting patients.
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