Hematemesis

Hematemesis, the vomiting of blood, usually indicates GI bleeding above the ligament of Treitz, which suspends the duodenum at its junction with the jejunum. Bright red or blood-streaked vomitus indicates fresh or recent bleeding. Dark red, brown, or black vomitus (the color and consistency of coffee grounds) indicates that blood has been retained in the stomach and partially digested.

Although hematemesis usually results from a GI disorder, it may stem from a coagulation disorder or a treatment that irritates the GI tract. Esophageal varices may also cause hematemesis. Swallowed blood from epistaxis or oropharyngeal erosion may also cause bloody vomitus. Hematemesis may be precipitated by straining, emotional stress, and the use of an anti-inflammatory or alcohol. In a patient with esophageal varices, hematemesis may be a result of trauma from swallowing hard or partially chewed food. (See Rare causes of hematemesis, page 320.)  

Hematemesis is always an important sign, but its severity depends on the amount, source, and rapidity of the bleeding. Massive hematemesis (vomiting 500 to 1,000 ml of blood) may be life-threatening.

Emergency interventions

If the patient has massive hematemesis, check his vital signs. If you detect signs of shock — such as tachypnea, hypotension, and tachycardia — place the patient in a supine position, and elevate his feet 20 to 30 degrees. Start a large-bore I

V. line for emergency fluid replacement. Also, send a blood sample for typing and crossmatching, hemoglobin level, and hematocrit and administer oxygen. Emergency endoscopy may be necessary to locate the source of bleeding. Prepare to insert a nasogastric (NG) tube for suction or iced lavage. A Sengstaken-Blakemore tube may be used to compress esophageal varices. (See Managing hematemesis with intubation

History and physical examination

If the patient’s hematemesis isn’t immediately life-threatening, begin with a thorough history. First, have the patient describe the amount, color, and consistency of the vomitus. When did he first notice this sign? Has he ever had hematemesis before? Find out if he also has bloody or black, tarry stools. Note whether hematemesis is usually preceded by nausea, flatulence, diarrhea, or weakness. Has he recently had bouts of retching with or without vomiting?

Next, ask about a history of ulcers or of liver or coagulation disorders. Find out how much alcohol the patient drinks, if any. Does he regularly take aspirin or other nonsteroidal anti-inflammatory drug (NSAID), such as phenylbutazone or indomethacin? These drugs may cause erosive gastritis or ulcers. Does he take warfarin or other drugs with anticoagulant properties? These drugs increase the patient’s risk of bleeding.

Begin the physical examination by checking for orthostatic hypotension, an early warning sign of hypovolemia. Take blood pressure and pulse with the patient in the supine, sitting, and standing positions. A decrease of 10 mm Hg or more in systolic pressure or an increase of 10 beats/minute or more in pulse rate indicates volume depletion. After obtaining other vital signs, inspect the mucous membranes, nasopharynx, and skin for signs of bleeding or other abnormalities. Finally, palpate the abdomen for tenderness, pain, or masses. Note lymphadenopathy.

Medical causes

Anthrax (GI)

Initial signs and symptoms after eating contaminated meat from an animal infected with the gram-positive, spore-forming bacterium Bacillus anthracis include a loss of appetite, nausea, vomiting, and a fever

Signs and symptoms may progress to hematemesis, abdominal pain, and severe bloody diarrhea.

Coagulation disorders

Any disorder that disrupts normal clotting may result in GI bleeding and moderate to severe hematemesis Bleeding may occur in other body systems as well, resulting in such signs as epistaxis and ecchymosis

Other associated effects vary, depending on the specific coagulation disorder, such as thrombocytopenia or hemophilia.

Esophageal cancer

A late sign of esophageal cancer, hematemesis may be accompanied by steady chest pain that radiates to the back Other features include substernal fullness, severe dysphagia, nausea, vomiting with nocturnal regurgitation and aspiration, hemoptysis, a fever, hiccups, a sore throat, melena, and halitosis.

Esophageal rupture

The severity of hematemesis depends on the cause of the rupture When an instrument damages the esophagus, hematemesis is usually slight

However, rupture due to Boerhaave’s syndrome (increased esophageal pressure from vomiting or retching) or other esophageal disorders typically causes more severe hematemesis. This life-threatening disorder may also produce severe retrosternal, epigastric, neck, or scapular pain accompanied by chest and neck edema. Examination reveals subcutaneous crepitation in the chest wall, supraclavicular fossa, and neck. The patient may also show signs of respiratory distress, such as dyspnea and cyanosis.

Esophageal varices (ruptured)

Life-threatening rupture of esophageal varices may produce coffee-ground or massive, bright red vomitus Signs of shock, such as hypotension or tachycardia, may follow or even precede hematemesis if the stomach fills with blood before vomiting occurs

Other symptoms may include abdominal distention and melena or painless hematochezia, ranging from slight oozing to massive rectal hemorrhage.

Gastric cancer

Painless bright red or dark brown vomitus is a late sign of gastric cancer, which usually begins insidiously with upper abdominal discomfort The patient then develops anorexia, mild nausea, and chronic dyspepsia unrelieved by antacids and exacerbated by food

Later symptoms may include fatigue, weakness, weight loss, feelings of fullness, melena, altered bowel habits, and signs of malnutrition, such as muscle wasting and dry skin.

Gastritis (acute)

Hematemesis and melena are the most common signs of acute gastritis They may even be the only signs, although mild epigastric discomfort, nausea, a fever, and malaise may also occur. Massive blood loss precipitates signs of shock. Typically, the patient has a history of alcohol abuse or has used aspirin or some other NSAID. Gastritis may also occur secondary to Helicobacter pylori infection.

Mallory-Weiss syndrome

Characterized by a mucosal tear of the mucous membrane at the junction of the esophagus and stomach, this syndrome may produce hematemesis and melena

It’s commonly triggered by severe vomiting, retching, or straining (as from coughing), most commonly in alcoholics or in people whose pylorus is obstructed Severe bleeding may precipitate signs of shock, such as tachycardia, hypotension, dyspnea, and cool, clammy skin.

Peptic ulcer

Hematemesis may occur when a peptic ulcer penetrates an artery, vein, or highly vascular tissue

Massive — and possibly life-threatening — hematemesis is typical when an artery is penetrated. Other features include melena or hematochezia, chills, a fever, and signs and symptoms of shock and dehydration, such as tachycardia, hypotension, poor skin turgor, and thirst. The patient may have a history of nausea, vomiting, epigastric tenderness, and epigastric pain that’s relieved by foods or antacids. He may also have a history of habitually using tobacco, alcohol, or NSAIDs.

Other causes

Treatments

Traumatic NG or endotracheal intubation may cause hematemesis associated with swallowed blood

Nose or throat surgery may also cause this sign in the same way.

Special considerations

Closely monitor the patient’s vital signs, and watch for signs of shock Check the patient’s stools regularly for occult blood, and keep accurate intake and output records. Place the patient on bed rest in a low or semi-Fowler’s position to prevent aspiration of vomitus. Keep suctioning equipment nearby, and use it as needed. Provide frequent oral hygiene and emotional support — the sight of bloody vomitus can be very frightening. Administer a histamine-2 receptor antagonist I

V.; vasopressin may be required for variceal hemorrhage. As the bleeding tapers off, monitor the pH of gastric contents, and give hourly doses of antacids by NG tube, as necessary.

Pediatric pointers

Hematemesis is much less common in children than in adults and may be related to foreign-body ingestion Occasionally, neonates develop hematemesis after swallowing maternal blood during delivery or breast-feeding from a cracked nipple

Hemorrhagic disease of the neonate and esophageal erosion may also cause hematemesis in infants; such cases require immediate fluid replacement.

Geriatric pointers

In elderly patients, hematemesis may be caused by a vascular anomaly, an aortoenteric fistula, or upper GI cancer In addition, chronic obstructive pulmonary disease, chronic liver or renal failure, and chronic NSAID use all predispose elderly people to hemorrhage secondary to coexisting ulcerative disorders.

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Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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