Case 4: Large-Volume Hematemesis in a 16-year-old Boy

Presentation

A 16-year-old Hispanic boy presents to our emergency department (ED) with recurrent episodes of bloody emesis. Two other episodes occurred 1 and 3 months before the current presentation. The volume of bloody emesis during these episodes was small and without associated hemodynamic instability. However, the family did not have any health insurance secondary to absence of a legal immigration status, declined further evaluation, and missed their follow-up appointments. In the ED, the patient is tachycardic and diaphoretic with a supine heart rate of 140 beats/min and blood pressure of 78/50 mm Hg, a respiratory rate of 25 breaths/min, and oxygen saturation of 95% on room air. He experiences a brief syncopal episode on sitting upright and is subsequently administered 2 normal saline boluses (1 L each). His initial hemoglobin level is noted to be 8 g/dL (80 g/L), and transfusion of 1 U of packed red blood cells is initiated. Initial laboratory values are noted as follows: serum sodium, 137 mEq/L (137 mmol/L); potassium, 4.2 mEq/L (4.2 mmol/L), chloride, 102 mEq/L (102 mmol/L), bicarbonate, 24 mEq/L (24 mmol/L), blood urea nitrogen, 26 mg/dL (9.3 mmol/L), creatinine, 0.68 mg/dL (51.9 μmol/L), albumin, 3.5 g/dL (35 g/L), aspartate aminotransferase, 30 U/L (0.50 μkat/L), alanine aminotransferase, 37 U/L (0.62 μkat/L), total bilirubin, 0.5 mg/dL (8.6 μmol/L), ammonia, 38 μg/dL (27.1 μmol/L), prothrombin time, 16.7 seconds, and activated partial thromboplastin time, 25 seconds. A nasogastric tube is inserted, and cold-water lavage is instilled, which causes the patient to have a large-volume bloody emesis. On arrival at the PICU, he is started on pantoprazole and octreotide drips, and the pediatric surgery and gastroenterology …