50/f w haematemesis

I vomited blood last night after waking up around 2am feeling nauseous. It then settled for awhile and I had a second vomit about half an hour later. This time there were sesame seed sized black bits in my vomit. 

Focused Hx: Did not wretch before vomiting. Denies abdo pain. Denies urinary (freq, noct, dys) sx, constipation/diarrhoea, Otherwise well nil meds nil medical hx.

O/E: Dry membranes, BP 100/65, HR 75. Afebrile. Abdo tender on deep palp of LLQ and L renal angle otherwise SNT bowel sounds present, no organomegaly. FWT trace blood nil leuks nil nitrates.

Ix: FBE U&E CRP LFT Amylase/Lipase normal. AXR (erect/supine) mild fecal loading otherwise n.

She looks a bit dry so you start her on 4/24 1000ml N. Along with this 40mg Esomeprazole is given as well.

The investigations came back and you are just about to discharge the patient with an outpatient gastroscopy referral when the nurse calls you out:

ATSP: pt has a BP of 90/59

You quickly examine the patient. Her ex findings are the same as before. GCS 15 alert and communicative. The bag is nearlly empty so she has been transfused roughly 800ml in the past three hours.

What would you do next?




1. Give additional Esomeprazole 40mg iv stat.
2. do not send home a patient with a bp of 90/60.
3. i/v bolus 250ml N. Saline and monitor BP.

She then stabilizes and maintains a BP of > 105/60 over the next two hours.

Surgical Registrar: Pt is for Cat-1 outpatient gastroscopy then r/v at a gastroenterology clinic.


Review: Upper Gastrointestinal Bleeding


Peptic Ulcer Disease: Mid/epigastric tenderness and pain. NSAIDs. Can present as coffee ground vomit.

Oesophagitis: Dysphagia, hx GORD

Mallory-Weiss Tear: Tends to be preceeded by wretching.

Oesophageal Varices: Sx of portal hypertension. Context of chronic liver disease. ETOH. Abdo varices.

Rare causes such as AV malformations, tumors, and gastric varices.


Essential Management:

1. Start PPI.
2. Monitor for hypovolaemic shock. Consider Surg/ICU.
3. Gastroscopy.

The real question is how urgent a gastroscopy needs to be done.