HPI

• 44 yo reported history of diabetes (not on any meds), heavy daily alcohol use (12 beers per day), no known history of liver or varices disease presents reporting abdominal pain x 12 hours
• Epigastric in location. Burning in character. Nothing makes it better or worse. Severe, 10/10.
• Pt reports associated hematemesis, bright red blood for the past 12 hours. He also reports melena for the past 12 hours. Unable to quantify.
• Abdominal pain and vomiting started about 1 hour after binge drinking 10 beers last night.

PE

Vitals T 98.8 BP 92/50 HR 148 Pox 97%

• Appears uncomfortable, pale, answers in mostly one word responses
• Lungs: clear bilaterally
• Heart: tachycardic
• Abdomen: soft, epigastric tenderness, no pulsatile masses

DDx for hematemesis

• Gastric and/or duodenal ulcers
• Severe or erosive gastritis/duodenitis
• Severe or erosive esophagitis
• Esophagogastric varices
• Angiodysplasia
• Mallory-Weiss syndrome

Management of unstable GI bleed 

• Closely monitor airway status
• Obtain and maintain at least two large bore IV access (16 gauge)
• Treat hypotension initially with bolus infusions of isotonic crystalloid
• Transfuse 2 to 4 units PRBCs on per institutional emergent protocol
• Obtain immediate consultation with gastroenterologist and intensivist
• Give a proton pump inhibitor
• If suspected varices, give octreotide and ceftriaxone
• Consider balloon tamponade with Blakemore tube as temporizing measure

Patient management and outcome

• Patient had one witnessed episode of large volume hematemesis in ED
• Intubated
• Received 2 units PRBC, PPI, octreotide, ceftriaxone
• GI performed emergent EGD and variceal banding in ICU

Take home pearls

• Patients will not regurgitate textbook buzz words like "varices, alcohol use disorder, portal hypertension, melena" when relaying their history!
• Do not anchor on triage note: this patient with esophageal varices and massive hematemesis requiring time sensitive intervention was triaged as: “Abdominal pain. Started yesterday. No vomiting. Diarrhea”

Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Med Clin North Am. 2008 May;92(3):491-509, xi. doi: 10.1016/j.mcna.2008.01.005. PMID: 18387374.