Hematemesis

Medical History

[accordion][accordion_item title=”History of Present Illness”]Patient is a [AGE] year old [fe]male who presents with [#] episode[s] of [bright red][coffee ground] vomiting that began [ONSET] prior to presentation. [Denies] blood mixed in stools. [Denies] tarry black stools.  [Denies] chest pain. [Denies] shortness of breath. [Denies] lightheadedness. [Denies] decreased exercise tolerance. [Denies] decreased urine output. [Denies] history of gastritis, GERD, or peptic ulcer disease.[Denies] history of hepatitis, heavy alcohol use, or liver disease. [Denies] history of abdominal surgeries. [Denies] history of anticoagulant use such as aspirin, plavix, rivaroxaban, and warfarin. [Denies] history of heart disease.[/accordion_item][accordion_item title=”Physical Exam”]Blood pressure was [ ], pulse was [ ], respirations were [ ], temperature was [ ] pulse ox was [ ]% on [room air]

General: [appear comfortable on stretcher.];
HEENT: Conjunctiva demonstrate [no] pallor. [no] scleral icterus. Oral mucosa is moist and well perfused. No visible sources of bleeding in eye, ear, nose, or throat.;
Cardiovascular: [Regular rate and rhythm];
Respiratory: Symmetric and clear breath sounds.;
Gastrointestinal: [No surgical scars.] [No] obvious hepatosplenomegaly, fluid wave. and spider angioma. [No] abdominal tenderness. Rectal exam notable for guaiac [negative] stools.;
Musculoskeletal: [Distal extremity is warm.];
Skin: [No] pallor. [No] jaundice. Distal capillary refill is less than 2 seconds.;
Neurologic: [The patient is oriented to person, place and time. Strength and sensation are grossly intact. Face is symmetric.];[/accordion_item][/accordion]

Medical Decision Making

[accordion][accordion_item title=”Initial Evaluation and Differential”]Patient presents with hematemesis.

I have considered serious and life-threatening causes of the patient’s presenting symptoms, which included a perforated peptic ulcer, arteriovenous malformation, aortoenteric fistula, and esophageal varices.

I have excluded the above diagnoses from consideration as it is inconsistent with my physical exam.[/accordion_item][accordion_item title=”Diagnostics”]Complete blood count

• Due to my inability to exclude the diagnosis of severe anemia. I decided to obtain a complete blood count, which was within expected limits.

Lactic acid

• Due to my inability to exclude the diagnosis of severe tissue perfusion. I decided to obtain a lactic acid, which was within expected limits.

Coagulation studies

• Due to my inability to exclude the diagnosis of coagulopathy secondary to either vitamin K inhibition or decreased hepatic synthetic function, I decided to obtain coagulation studies, which were within expected limits.

Liver function tests

• Due to my inability to exclude the diagnosis of hepatic dysfunction, I decided to obtain liver function tests, which were within expected limits.

Renal function tests

• Due to my inability to exclude the diagnosis of acute kidney injury, I decided to obtain renal function studies, which were within expected limits.

Troponins

• Due to my inability to exclude the diagnosis of acute coronary syndrome triggered by acute loss of intravascular function, I decided to order a troponin study, which was negative.

Plain upright abdominal film

• Due to my inability to exclude the diagnosis of a perforated peptic ulcer, I decided to obtain an upright plain abdominal film, which was not notable for free air.

CT of the abdomen and pelvis with contrast

• Due to my inability to exclude the diagnosis of aortoenteric fistula and malignancy, I decided to obtain a CT of the abdomen and pelvis with contrast, which demonstrated no gross abnormalities.

Type and screen

• Type and screen was sent to anticipate for potential need for blood products.

[/accordion_item][accordion_item title=”Intervention”]Initial

• Given my concern for acute volume loss, large bore IVs was established and continuous blood pressure monitoring was instituted. Volume loss was immediately replaced intravenously with [#]L of normal saline.

PPI

• Because the patient [has a history of gastric diseases] [have signs that suggest peptic ulcers as a cause of their symptoms], I have initiated treatment with initial bolus of 80mg of IV pantoprazole followed by a continuous infusion of 8mg/hr for 72 hours. I have done this because PPI has a significant mortality benefit, and decrease the rate of rebreeding and surgical intervention.

Antibiotics (w/w/o octreotide)

• Because the patient [has a history of liver diseases][have signs that suggest variceal bleeding as a cause of their symptoms], I have administered 1g of IV ceftriaxone as antibiotics have shown to offer a survival benefit to patents with variceal bleeding. [50mcg of IV octreotide was also administered.]

Blood

• [#] units of packed red blood cells was transfused [with platelets and fresh frozen plasma] [due to inadequate improvement to perfusion after initial crystalloid resuscitation][due to obvious signs of ongoing hemorrhage and shock state].
• I have discussed the proposed blood product transfusion with [the patient]. I have informed them regarding the potential risks of blood product transfusions which, though rare, include transfusion reaction, hepatitis, and AIDS. They been given the opportunity to ask questions about the need to be transfused and the possible results of not receiving this treatment. They have agreed to undergo the transfusion.

• I have consulted the [general surgery][gastroenetrologist] regarding the patient’s significant upper GI bleeding as they will likely require emergent evaluation with endoscopy within the next 24 hours. They are recommending [RECOMMENDATION].

[/accordion_item][accordion_item title=”Disposition”]

• Because the patient’s BUN is >18.2, hemoglobin is [>13][>12][at their baseline], systolic blood pressure is >110, pulse is <100, and does not have a history of congestive heart failure, cardiac failure, or liver disease, and did not present with alarming symptoms such as syncope and melena, they can be managed as an outpatient based on recommendations by The American College of Gastroenterology.
• I have asked the patient to return to the ED should they have another episode of bloody emesis, bloody bowel movement, or black tarry stools or if they experience symptoms of worsening lightheadedness, syncope, chest pain, or shortness of breath.

• Due to my inability to exclude an ongoing gastrointestinal hemorrhage, organ hypoperfusion, and potential for hemodynamic compromise and collapse from consideration, the patient require further evaluation and management in an inpatient setting.

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