Diagnose It Answer — August 22, 2026
ALL CLUES
A 54-year-old man arrives by ambulance after vomiting a large volume of bright red material at home. He reports lightheadedness, nausea, and profound weakness over the past two hours.
Long-standing alcohol use disorder with cirrhosis diagnosed three years ago. He takes propranolol daily and was scheduled for a screening endoscopy he never attended. No NSAID use.
HR 122 and thready, BP 86/48, RR 24, Temp 36.4 °C, SpO2 96% on room air. He is tachycardic and orthostatic, with a MAP of 61.
Pallor with cool, clammy extremities and capillary refill of 4 seconds. Abdomen is distended with shifting dullness. Spider angiomata across the chest and palmar erythema are present. Rectal exam reveals black, tarry melena.
Hgb 6.8 g/dL, down from a baseline of 12.1 g/dL. Platelets 68,000/µL. INR 1.9. BUN 42 mg/dL with creatinine 1.0 mg/dL, an elevated ratio consistent with digested blood in the gut. Urgent endoscopy shows actively spurting submucosal columns in the distal esophagus.
Variceal hemorrhage is the most lethal complication of portal hypertension, carrying a mortality near 20% at six weeks. Nurses must recognize that a cirrhotic patient vomiting blood is a hemodynamic emergency: establish two large-bore IVs, type and crossmatch, and anticipate octreotide plus prophylactic antibiotics before endoscopy. A rising BUN with a normal creatinine signals a large blood load in the gut. Monitor the airway closely, since aspiration during hematemesis is a leading cause of death, and prepare for balloon tamponade if bleeding cannot be controlled.
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