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Hematemesis

  • Common ddx

    • varices, mallory-weiss tear, esophagitis, gastritis
  • Don't miss

    • cancer, coagulopathy
  • Other ddx

    • iatrogenic, AVMs
  • Admission orders

    • Admit: ICU
    • Diagnosis: Upper GI Bleed
    • Condition: Guarded
    • Vital Signs: Per ICU routine
    • Allergies:
    • Nursing:
      • NG tube
      • Maintain two 16G or larger IVs at all times
      • Strict I/Os
      • DVT prophylaxis, TED stockings, SCDs
    • Diet: NPO for endoscopy
    • Activity: Bedrest, Advance as Tolerated
    • Labs:
      • CBC with platelets
      • HCT q 2 hr x 6
      • Chem
      • LFTs
      • coags:PT/INR, PTT
      • FOBT
      • ECG
      • Type and cross 4 units of packed RBCs
    • IV: 2 L NS, then House Officer (HO) Will Reassess
    • Special: surgical consult, endoscopy
    • Medications:
      • Pantoprazole 80-mg IV bolus over 2 minutes followed by pantoprazole 8 mg/h drip for 72 hours
      • d/c all NSAIDs
      • if varices:
        • Octreotide 50 mg bolus followed by 50 mg per hour infusion
        • Ofloxacin 400 mg IV qd x 7 days, first dose before endoscopy or Norfloxacin 400 mg PO bid x 7 days
        • Propranolol 10 mg PO tid, starting when patient is stable and able to tolerate oral intake
    • Call house officer: HR > 100 bpm, SBP < 100 mmHg
  • Discharge

    • criteria: no rebleeding within 48-72 hours
    • outpatient studies: f/u H. pylori, biopsy results
  • Esophagus ddx

    • varices, Mallory-Weiss tear, esophageal rupture, Boerhaave syndrome (suprasternal notch crepitus), foreign body (child), esophagitis (corrosive ingestion), GERD, cancer (dysphagia)
  • Stomach ddx

    • PUD, gastritis, stomach cancer
  • Heme ddx

    • coagulopathy, hemophilia, vWD, TTP, thrombocytopenia, leukemia
  • HPI

    • onset
    • quality: frank blood vs coffee grounds
    • quantity, frequency
    • triggering events, aggravates, alleviates
  • ROS

    • hematemesis (vomit) vs hemoptysis (cough)
    • fever, nightsweats, wt loss
    • ENT: dysphagia, odynophagia, reflux, corrosive ingestion
    • cardio: chest pain
    • pulm: cough, dyspnea
    • GI: retching, nausea, vomiting, diarrhea, hematochezia, abdominal pain
    • heme: easy bleeding, bruising, rash, petechiae
  • FH

    • coagulopathy
  • SH

    • EtOH
    • tobacco
  • Meds

    • anticoagulants
  • Allergies

  • Px

    • vitals
    • general impression
    • skin: rash, petechiae, bruising
    • ENT: blood in throat
    • cardio
    • pulm
    • GI: abdominal tenderness, rebound, mass
    • lymphadenopathy

  • Print | Citations

    Disclaimer: MDHero Workups is for educational use only, and is not meant to replace the clinical judgement of a professional. We do not guarantee the accuracy of any information on this website.