Immediate casualty management

1. ABC resuscitation
   • Assess airway protection, especially if continuing hematemesis, drowsiness, or aspiration risk.
   • Continuous pulse oximetry, ECG, BP monitoring, urine output.
   • Keep nil per oral.
   • Two wide-bore IV cannulas. Give oxygen only if hypoxemic.
   • IV crystalloid cautiously while arranging blood, particularly because of cardiac history.
2. Urgent investigations
   • CBC with platelet count, blood group and cross-match.
   • PT/INR, aPTT, renal function, electrolytes, liver function tests, glucose.
   • ECG, troponin if ischemic symptoms/ECG changes, and baseline echocardiography only if clinically required.
   • Specifically establish:
     • Type of mitral valve: mechanical or bioprosthetic
     • All drugs and last doses: warfarin, acenocoumarol, aspirin, clopidogrel, DOAC, NSAIDs, steroids
     • Prior peptic-ulcer disease, liver disease, alcohol use, melena or syncope.
3. Blood products
   • Use a restrictive transfusion strategy in most UGIB, but in this patient with significant coronary disease, consider PRBC transfusion at hemoglobin below about 8 g/dL, or earlier for ongoing instability/ischemia. The ACG UGIB guideline otherwise uses 7 g/dL for most hospitalized patients.
   • Correct thrombocytopenia or major coagulopathy in consultation with specialists.
4. Start medical treatment
   • IV proton-pump inhibitor: for example pantoprazole 80 mg IV bolus followed by 8 mg/hour infusion, or an accepted intermittent high-dose IV PPI regimen per local protocol.
   • Consider IV erythromycin before endoscopy if there is substantial blood in the stomach and no contraindication.
   • Do not give octreotide and antibiotic prophylaxis routinely unless there is evidence/suspicion of portal hypertension or variceal bleeding.

Antithrombotic management is the key issue

• Withhold warfarin/other anticoagulant temporarily while actively bleeding and obtain INR urgently.
• If she has a mechanical mitral valve, she is at high thrombotic risk. Do not make a prolonged interruption plan without cardiology input.
• If bleeding is major, ongoing, or hemodynamically significant with high INR from warfarin, discuss urgent reversal using 4-factor prothrombin complex concentrate (PCC) with gastroenterology, cardiology, and hematology. Management of vitamin K should be individualized in a mechanical-valve patient because it can delay safe re-anticoagulation.
• If on aspirin for secondary cardiac prevention, guideline advice generally favors continuing it if possible, or resuming it as soon as endoscopic hemostasis is confirmed. Do not independently stop dual antiplatelet therapy in a post-CABG/coronary patient without cardiology review. The ACG-CAG antithrombotic guideline addresses these competing bleeding and thrombotic risks.

Definitive evaluation and treatment

• Calculate a Glasgow-Blatchford score, but this patient should be admitted regardless, given hematemesis for 3 days and probable antithrombotic therapy.
• Arrange upper GI endoscopy within 24 hours after hemodynamic stabilization, and sooner if there is continued bleeding or instability.
• Endoscopy can diagnose and treat peptic ulcer bleeding, erosive disease, Mallory-Weiss tear, malignancy, angiodysplasia, etc. Blood-tinged vomiting after repeated retching can be due to a Mallory-Weiss tear, but painless ulcer or anticoagulant-related bleeding remains possible.
• If endoscopic hemostasis fails or there is recurrent major bleeding: repeat endoscopy, then CT angiography and interventional-radiology embolization, with surgery as rescue.