Hematemesis overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: John Fani Srour, M.D.

Hematemesis or haematemesis is the vomiting of blood. The source is generally the upper gastrointestinal tract (UGI). Patients can easily confuse it with hemoptysis (coughing up blood), although the former is more common. The most common causes of upper GI bleeding include bleeding peptic ulcer disease, gastritis, and variceal bleed. A nasogastric tube lavage that yields blood or coffee-ground like material confirms the diagnosis and predicts whether bleeding is caused by a high-risk lesion. The initial evaluation of the patient with UGI bleeding involves an assessment of hemodynamic stability and resuscitation if necessary. Upper endoscopy usually follows, with the goal of both diagnosis, and in some circumstances, treatment of the specific disorder. Important elements of the history include use of NSAIDs, alcohol, history of liver disease or variceal bleeding, history of ulcers, weight loss, dysphagia, or an abdominal aortic aneurysm (AAA). The latter may indicate aortoenteric fistula. Any recent surgical procedure especially one involving the GI tract is also relevant. Endoscopic, clinical, and laboratory features are useful for risk stratification of patients who present with UGI bleeding. In addition, gastroenterology and surgical consultation are usually required, especially for high risk patients.

Hematemesis must be differentiated from hemoptysis.

Blood tests, such as a complete blood count (CBC), blood chemistries, blood clotting tests, and liver function tests, are used to assess the condition of the patient.

Chest X ray in a patient with hematemesis should be ordered to exclude aspiration pneumonia, effusion, and esophageal perforation.

CT scan may be indicated to evaluate liver disease with cirrhosis, cholecystitis with hemorrhage, pancreatitis with pseudocyst and hemorrhage, aortoenteric fistula, and other unusual causes of upper gastrointestinal hemorrhage.

Angiography may be useful if bleeding persists and endoscopy fails to identify a bleeding site. As salvage therapy, embolization of the bleeding vessel can be as successful as emergent surgery in patients who have failed a second attempt of endoscopic therapy. Nuclear medicine scans may be useful to determine the area of active hemorrhage.

Endoscopy and biopsy can be used to indicate the diseases in esophagus, stomach and duodenum. Also, bleeding can be stanched through the tube. If abnormal areas are noted, tissue samples can be obtained through the endoscope. The tissue samples will be checked to identify the cause of bleeding.

Surgery or angiographic therapy is needed to patients who seem unstable or bleeding continues after initial resuscitation.

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