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What initial assessments should I perform for a patient presenting with haematemesis in primary care?
Answer
Guideline-Aligned (High Confidence)
Generated by iatroX. Developer: Dr Kola Tytler MBBS CertHE MBA MRCGP (General Practitioner).
Last reviewed: 16 August 2025
Initial assessments for a patient presenting with haematemesis in primary care should include:
- Risk Assessment and Referral Urgency: For patients over 16, use the Blatchford score at first assessment 1. For children with blood-stained vomit (haematemesis) not caused by ingested blood (e.g., nosebleed or cracked maternal nipple), arrange same-day hospital admission if it is associated with bile-stained vomiting, abdominal tenderness, mass, distension, frequent forceful vomiting (in infants up to two months), fever, systemic unwellness, dehydration, or dysphagia 3. Haematemesis in adults warrants consideration of non-urgent, direct access upper gastrointestinal endoscopy for suspected oesophageal or stomach cancer 2. The urgency of referral to secondary care for acute upper gastrointestinal bleeding depends on the patient's haemodynamic stability 1.
- Medication Review: Stop other non-steroidal anti-inflammatory drugs (NSAIDs), including cyclooxygenase-2 (COX-2) inhibitors, during the acute phase 1. Discuss the risks and benefits of continuing clopidogrel (or any other thienopyridine antiplatelet agents) with an appropriate specialist (for example, a cardiologist or a stroke specialist) and with the patient 1.
- General Clinical Assessment: Perform a general examination, including temperature, pulse, and respiratory rate 6. Assess the condition of the oral cavity 6. Examine the abdomen for tenderness, swelling, or distension; signs of intestinal obstruction; organomegaly; or constipation 6. If faecal impaction is suspected, perform a rectal examination 6. If increased intracranial pressure is a possibility, check the fundi for papilloedema 6. Ask about the onset, frequency, intensity, relieving and exacerbating factors, and relationship to vomiting 6. Inquire about other symptoms such as dyspepsia, heartburn, reflux, fullness, early satiety, constipation, diarrhoea, flatus, cough, headache, or confusion 6. Review the patient's treatment history (including simple measures, current medication, chemotherapy, anti-emetics, and radiation) and medical history (for example, ulcers or bowel surgery) 6. Assess the effect on nutrition and quality of life 6. Consider blood tests to exclude hypercalcaemia or uraemia, and other useful tests such as liver function tests and blood glucose level 6. Consider tests to exclude a urinary tract infection 6.
- Communication: Establish good communication with the patient and their family and carers at the time of presentation, providing consistent verbal information that is recorded in medical records, and written information where appropriate 1.
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