Hematemesis
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Here is a comprehensive overview of hematemesis drawn from authoritative surgical and emergency medicine textbooks.
Hematemesis
Definition
Hematemesis is the vomiting of blood — either bright red (fresh, ongoing bleeding) or dark "coffee-ground" material (blood partially degraded by gastric acid, indicating bleeding has slowed or stopped). It is a cardinal sign of upper gastrointestinal (GI) bleeding, meaning a source proximal to the ligament of Treitz.
Causes
Upper GI Bleeding (most common sources)
| Clinical Scenario | Likely Cause |
|---|---|
| Epigastric pain + hematemesis in NSAID/aspirin user | Peptic ulcer disease (most common — ~40–50%) |
| History of GERD/heartburn + hematemesis | Esophagitis / esophageal ulceration |
| Vomiting/retching followed by hematemesis | Mallory-Weiss tear (longitudinal mucosal tear at GEJ) |
| Painless hematemesis + liver disease / alcohol use | Gastroesophageal varices |
| Intermittent massive bleeding without NSAID/liver disease | Dieulafoy lesion (submucosal artery, often lesser gastric curvature) |
| Prior aortic graft + "herald" bleed | Aortoenteric fistula (rare but catastrophic) |
| Repeated bouts in patient with tropical exposure | Hepatosplenic schistosomiasis |
Other causes include: arteriovenous malformations, GI malignancy, erosive gastritis, swallowed blood from ENT sources.
Pathophysiology
- Bright red hematemesis → recent or ongoing bleeding (blood has not been exposed to gastric acid long enough to oxidize)
- Coffee-ground emesis → blood degraded by acid; suggests bleeding has slowed
- Melena (black tarry stools) often accompanies hematemesis — caused by bacterial degradation of as little as 50 mL of blood in the upper GI tract
Initial Assessment
History
- Character of vomitus (bright red vs. coffee-ground)
- Associated symptoms: retching, epigastric pain, syncope
- Medications: NSAIDs, aspirin, anticoagulants, glucocorticoids — all increase risk
- Alcohol use (varices, erosive gastritis, Mallory-Weiss)
- Prior GI bleeds; prior aortic surgery
- Note: iron and bismuth can mimic melena; red food dyes can mimic hematochezia
Physical Examination
- Visual inspection of vomitus is the most reliable method to confirm upper GI bleeding in the ED
- Vital signs: hypotension, tachycardia, narrowed pulse pressure, tachypnea
- Stigmata of chronic liver disease (jaundice, spider angiomata, splenomegaly → varices)
- Digital rectal exam: melena vs. hematochezia
Risk Stratification
The Glasgow-Blatchford Score (GBS) is the most validated tool for upper GI bleeding:
- GBS ≥ 7 → predicts need for endoscopic intervention
- GBS ≤ 1 → safe for outpatient management
Other tools: Rockall score, AIMS65 score.
Management
1. Airway
- Protect the airway first — respiratory insufficiency, altered mental status, or ongoing hematemesis are indications for endotracheal intubation before endoscopy
- Prophylactic intubation in stable patients is NOT indicated (increases pulmonary complications)
2. Resuscitation
- IV access × 2, fluid resuscitation
- Blood transfusion as needed (restrictive strategy — target Hb ~7–8 g/dL in stable patients, higher in cardiovascular disease)
3. Pharmacotherapy
| Drug | Indication | Dose |
|---|---|---|
| PPI (e.g., omeprazole) | Non-variceal peptic ulcer bleeding | 80 mg IV bolus → 8 mg/h infusion |
| Octreotide | Variceal/suspected variceal bleeding | 50 µg bolus → 25–50 µg/h infusion |
| Antibiotics (ciprofloxacin 400 mg IV or ceftriaxone 1 g IV) | Cirrhotic patients (prevent bacterial translocation) | As soon as possible |
| Erythromycin / metoclopramide | Promotility before endoscopy | Improves endoscopic visualization |
4. Endoscopy
- Upper GI endoscopy is the investigation and treatment of choice
- Timing:
- Unstable patients: within 6–24 hours after resuscitation
- Stable patients: within 12–36 hours
- Hemostatic techniques: variceal band ligation, sclerotherapy; clips, thermocoagulation, epinephrine injection for ulcers
5. Balloon Tamponade
- Sengstaken-Blakemore tube — reserved for life-threatening variceal bleeding as a temporary bridge to endoscopy or transfer
- Not a definitive treatment
6. Interventional/Surgical
- Angiography with embolization if endoscopy fails
- Surgery (e.g., TIPSS for varices) for refractory cases
Key Pearls
- 14% of apparent lower GI bleeds actually originate from an upper GI source
- BUN:Creatinine ratio > 30 is a clinical clue pointing to an upper GI source
- Mallory-Weiss tears classically follow retching — often self-limited
- Dieulafoy lesions cause massive intermittent bleeding and are notoriously difficult to diagnose endoscopically
- Aortoenteric fistula presents with a self-limited "herald bleed" before catastrophic hemorrhage — always ask about prior aortic surgery
Sources: Mulholland and Greenfield's Surgery, 7e; Tintinalli's Emergency Medicine, 8e
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