Hematemesis in a Patient With Alcohol Use Disorder

Case Study

A rapid response event was initiated by the bedside nurse after the patient had an episode of large volume, bloody vomiting. On prompt arrival of the rapid response team, it was noted that the patient was a 28-year-old male with a known history of alcohol use and IV drug abuse who was admitted earlier for alcohol withdrawal syndrome and two episodes of bloody vomiting. A quick review of his charts indicated that the patient’s hemoglobin had been trending down.

Vital Signs

Temperature: 98.2 °F, axillary Blood Pressure: 100/54 mmHg Pulse: 109 beats per min (bpm) – sinus rhythm on telemetry Respiratory Rate: 28 breaths per min Pulse Oximetry: 95% saturation on room air

Focused Physical Examination

A quick exam showed a young, jaundiced male in moderate distress, with blood all over his hospital gown. The patient was using accessory muscles of respiration. He had evidence of fresh, bright red blood in his mouth as well. His lungs were clear on auscultation. His cardiac exam was significant for tachycardia but was otherwise unremarkable. His abdomen was distended with dullness to percussion in flanks. No tenderness on palpation was appreciated.

Interventions

A cardiac monitor with pads was attached. Two large-bore IV lines were established. A stat order of a liter bolus of lactated ringers was administered. Stat labs were drawn, including a complete blood count (CBC), serum chemistry, liver tests, coagulation studies, and type and screen. Consent was obtained from the patient to allow for blood transfusion if required. Emergent placement of advanced airway was deferred at the time given stable oxygen saturation on room air and the ability of the patient to protect his airway. Pantoprazole (80 mg), ceftriaxone, and octreotide were ordered to be given intravenously. Stat consult was obtained from gastroenterology, and the patient was transferred to the intensive care unit (ICU), where he underwent elective intubation and upper GI endoscopy for suspected variceal banding.

Final Diagnosis

Acute upper gastrointestinal (GI) bleeding.

Upper Gastrointestinal Bleeding

Bleeding from an upper GI source usually presents as hematemesis, coffee-ground emesis, or melena. Hematemesis, or frank bloody emesis, is indicative of moderate to severe active bleeding. Patients can also present with hematochezia in cases with very brisk bleeding (5%-10% cases of hematochezia). The common causes of upper GI bleed are discussed in Table 51.1 .

Table 51.1

Common causes of upper gastrointestinal bleed

Ulcerative	Vascular
• Peptic ulcer disease – most common cause • Esophagitis • Gastritis	• Angiodysplasia • Esophageal and gastric varices • Dieulafoy lesion • Gastric antral vascular atresia