• Upper gastrointestinal bleeding, such as a bleeding stomach or duodenal ulcer, gastritis, or tear in the esophagus after retching (Mallory-Weiss tear)
• Bleeding esophageal or gastric varices, especially with liver disease, heavy alcohol use, jaundice, or abdominal swelling
• Blood swallowed from a nosebleed or bleeding mouth, though this must not be assumed
• The “vertigo” may be worsening due to blood loss, low blood pressure, anemia, or dehydration
• Vertigo could also be a separate inner-ear disorder, but serious neurologic causes such as posterior circulation stroke need urgent exclusion, especially if there is new weakness, facial droop, slurred speech, double vision, severe headache, inability to walk, or loss of coordination.

1. Keep the patient lying on their side or sitting forward if actively vomiting, to reduce choking/aspiration risk.
2. Do not give food, drink, alcohol, aspirin, ibuprofen, naproxen, or other pain medicines unless emergency clinicians instruct otherwise.
3. Do not give medicines for vertigo or vomiting if the person is drowsy, confused, or continuing to vomit blood.
4. If they become unconscious but are breathing, place them in the recovery position. If not breathing normally, start CPR if trained.
5. Bring or photograph all medication packets, particularly blood thinners such as warfarin, apixaban, rivaroxaban, dabigatran, clopidogrel, or aspirin.

1. Immediate safety and working diagnosis

• “Do you think the blood is true hematemesis from the stomach/food pipe, or could it be swallowed blood from the nose or mouth?”
• “Is the patient currently stable: blood pressure, pulse, oxygen level, and hemoglobin?”
• “Does this need hospital admission, urgent gastroenterology review, or urgent endoscopy?”
• “What is the leading diagnosis you are considering, and what dangerous conditions are you trying to rule out?”

2. Questions about the vomiting blood

• “Could this be a bleeding peptic ulcer, gastritis, a tear from vomiting, or varices?”
• “Will you check CBC/hemoglobin, platelet count, blood group and cross-match, clotting tests, liver and kidney tests?”
• “Is an upper GI endoscopy needed, and how urgently?”
• “Could any current medication be contributing, particularly aspirin, ibuprofen, naproxen, clopidogrel, warfarin, apixaban, rivaroxaban, or steroids?”
• “Are there signs suggesting liver disease or esophageal varices?”

3. Questions about the vertigo and brain scan

• “Are you concerned about a cerebellar/posterior circulation stroke or brain hemorrhage?”
• “Has a focused neurologic examination been done, including eye movements/nystagmus, limb coordination, gait, speech, sensation, and strength?”
• “Are there any features suggesting an inner-ear cause such as vestibular neuritis, BPPV, or labyrinthitis?”
• “If CT is normal but concern for posterior stroke remains, is MRI brain with diffusion imaging or CT angiography needed?”
• “Could low blood pressure or anemia from bleeding be causing dizziness that feels like vertigo?”

4. History to tell the physician clearly

• Is it true spinning sensation, lightheadedness, faintness, or imbalance?
• Sudden or gradual onset? Continuous for 3 days or brief attacks triggered by turning in bed?
• Hearing loss, tinnitus, ear fullness, ear pain, recent viral illness?
• Severe headache, neck pain, double vision, slurred speech, weakness, numbness, facial droop, swallowing difficulty, or inability to walk unaided?
• Amount and appearance of blood: bright red, dark brown, or “coffee-ground” material?
• Black tarry stool, abdominal pain, chest pain, repeated retching, alcohol use, known ulcer, liver disease, or prior GI bleeding?
• Any blood-thinner or anti-inflammatory medications?
• Age and stroke-risk factors: high blood pressure, diabetes, smoking, high cholesterol, irregular heartbeat, prior TIA/stroke?

A. Causes of vomiting blood (hematemesis)

Common and important upper gastrointestinal causes

1. Peptic ulcer bleeding - stomach or duodenal ulcer, often linked to H. pylori, aspirin, ibuprofen, naproxen, steroids, or blood thinners.
2. Erosive gastritis or gastropathy - inflammation/erosions of the stomach, including from NSAIDs, alcohol, stress, or severe illness.
3. Esophagitis - esophageal inflammation, commonly from reflux, pills, infection, or caustic injury.
4. Mallory-Weiss tear - a tear at the lower esophagus/upper stomach after repeated retching or vomiting. This is a possible link if vertigo caused severe vomiting first.
5. Esophageal or gastric variceal bleeding - enlarged veins that rupture, usually in cirrhosis/portal hypertension. Can cause massive bright-red hematemesis.
6. Esophageal, stomach, or duodenal cancer - less common but must be considered in older patients, weight loss, progressive swallowing difficulty, or chronic anemia.
7. Vascular lesions - Dieulafoy lesion, angiodysplasia/arteriovenous malformation, gastric antral vascular ectasia.
8. Portal hypertensive gastropathy - bleeding stomach lining due to portal hypertension.
9. Cameron lesions - erosions in a large hiatus hernia.
10. Duodenitis.

Less common but serious causes

1. Aortoenteric fistula - especially if there has been previous aortic aneurysm repair or an aortic graft.
2. Hemobilia - bleeding from the biliary system, often after liver/bile-duct procedures or trauma.
3. Hemosuccus pancreaticus - bleeding through the pancreatic duct, usually related to pancreatitis or a pancreatic pseudoaneurysm.
4. Swallowed blood from a heavy nosebleed, oral bleeding, dental procedure, or coughing blood that is then swallowed.
5. Bleeding tendency due to low platelets, liver failure, leukemia, kidney failure, anticoagulants, antiplatelet drugs, or clotting disorders.
6. Rare systemic infections or vasculitis causing gastrointestinal bleeding.

B. Causes of vertigo

Inner-ear/peripheral vestibular causes

1. Vestibular neuritis - continuous severe vertigo lasting days, often after a viral illness, usually without hearing loss.
2. Labyrinthitis - vertigo with hearing loss, tinnitus, or ear symptoms.
3. Benign paroxysmal positional vertigo (BPPV) - brief attacks triggered by turning in bed, looking up, or position change. It usually does not cause continuous vertigo for 3 days or vomiting blood.
4. Ménière disease - episodic vertigo with fluctuating hearing loss, tinnitus, and ear fullness.
5. Vestibular migraine - vertigo with or without headache, often in someone with migraine history.
6. Ear infection or mastoiditis.
7. Ramsay Hunt syndrome - ear pain/rash, facial weakness, hearing symptoms, vertigo.
8. Perilymph fistula - after trauma, pressure injury, heavy lifting, or ear surgery.
9. Ototoxic drug effect - for example some antibiotics, chemotherapy agents, loop diuretics, or salicylate toxicity.
10. Acoustic neuroma/vestibular schwannoma - usually slower onset with one-sided hearing loss, but included in the broader differential.

Brain, blood-vessel, and neurologic causes that must be excluded urgently

1. Cerebellar ischemic stroke.
2. Brainstem/posterior circulation stroke.
3. Cerebellar hemorrhage.
4. Posterior circulation transient ischemic attack (TIA).
5. Vertebral artery dissection - especially if neck pain or headache followed trauma, sudden neck movement, chiropractic manipulation, or strenuous activity.
6. Multiple sclerosis or other inflammatory brainstem disease.
7. Brain tumor or posterior fossa mass.
8. Seizure-related dizziness or migraine with brainstem aura, less commonly.

C. Conditions that can cause dizziness mistaken for vertigo, especially after bleeding

1. Acute blood loss/anemia from the GI bleed - can cause faintness, weakness, dizziness, palpitations, and low blood pressure. Patients may call this “vertigo,” though it is often presyncope rather than true spinning.
2. Low blood pressure/shock due to ongoing bleeding or dehydration.
3. Dehydration from vomiting and poor intake.
4. Low blood sugar.
5. Abnormal heart rhythm, heart attack, or reduced cardiac output.
6. Medication effects, including blood-pressure medicines, sedatives, alcohol, drugs for anxiety, or vertigo medicines.
7. Electrolyte disturbance, particularly sodium or potassium abnormalities.
8. Severe infection/sepsis.
9. Pregnancy-related nausea/vomiting with an unrelated GI bleed, where relevant.

The most important possibilities in this case

1. Upper GI bleed causing blood loss, dehydration, and dizziness
2. Mallory-Weiss tear after severe vomiting from vertigo
3. Bleeding ulcer/gastritis
4. Variceal bleeding, if there is liver disease or heavy alcohol use
5. Cerebellar or brainstem stroke, especially if vertigo is continuous or there is inability to walk, double vision, speech trouble, weakness, numbness, severe headache, or new neck pain
6. Two simultaneous conditions, such as vestibular neuritis plus a bleeding ulcer