creation date: 2025-11-24 17:48
tags: Workups
Hematemesis
Background
Hematemesis refers to vomiting of blood. The source of the blood is most commonly due to upper gastrointestinal bleed. However, in rare cases, it may be from the upper respiratory track (eg. epistaxis).
Pathophysiology
A number of conditions can result in bleeding of the upper GI tract. This includes the esophagus, stomach, or duodenum (proximal to ligament of Treitz).
The blood vomited can range from bright red to brown, including appearing like coffee ground. The darker, coffee-ground appearance is due to the oxidation of iron within the blood by the stomach acid.
Most common causes are ulcerative/erosive lesions within the GI tract. Less common are vascular lesions, mass lesions, or traumatic lesions.
In cases of unidentified lesions, the source of bleeding is typically either an obscure lesion (eg. Dieulafoy’s), obscured by a retained blood clot during endoscopy, or had already healed by time of investigation.
Differential Diagnosis
The most common causes of upper GI bleed in order of frequency include:
- Peptic (gastric and/or duodenal) ulcers - due toH. pylori infection, NSAIDs use, physiologic stress, excess gastric acid
- Severe or erosive gastritis/duodenitis
- Severe or erosive esophagitis
- Esophagogastric varices - due to portal hypertension
- Portal hypertensive gastropathy
- Angioectasia (also known as angiodysplasia or vascular ectasia)
- Mallory-Weiss syndrome
- Mass lesions (polyps/cancers)
- No lesion identified (10 to 15 percent of patients)
Uncommon causes include:
- Dieulafoy’s lesion (dilated aberrant submucosal artery that erodes the overlying epithelium without primary ulcer)
- Gastric antral vascular ectasia
- Hemobilia
- Hemosuccus pancreaticus
- Aortoenteric fistula
- Cameron lesions
- Ectopic varices
- Iatrogenic bleeding after endoscopic interventions
Initial Evaluation
Evaluate hemodynamic stability
Severe upper GI bleeding constitutes an emergency may lead to hypovolemic shock.
History
History should assess other findings relating to GI bleedings (eg. melena).
An assessment of past medical history should be made for consideration of bleeding from the same source:
- History of cirrhosis or liver disease (varices, portal hypertensive gastropathy)
- History of H. pylori or NSAID use (peptic ulcer disease, gastroduodenal erosion)
- History of gastroenteric anastomosis (marginal ulcer)
- History of abdominal aortic aneurysm or aortic graft (aorto-enteric fistula)
- Tobacco use (peptic ulcer disease, malignancy)
- Excess alcohol use (gastric erosion, subepithelial hemorrhage, prolapse gastropathy, malignancy, cirrhosis, liver disease)
An assessment of cormobid conditions should be done as they may alter management:
- CAD/myocardial ischemia (risk of anemia adverse effects)
- CKD or CHF (fluid overload)
- Coagulopathies or thrombocytopenia (for bleed control)
- Dementia or hepatic encephalopathy (aspiration risk)
Medications that may affect presentation and treatment:
- Anticoagulants and antiplatelets
- Aspirin, NSAIDs - peptic ulcer risk
- Antibiotics (tetracycline), bisphosphonates, NSAIDs - pill esophagitis
- Iron, bismuth, charcoal, licorice - may darken stool
Associated symptoms and signs include:
- Emesis, retching, coughing prior to hematemesis (Mallory-Weiss tear)
- Jaundice, abdominal distension from ascites (variceal hemorrhage or portal hypertension gastropathy)
- Upper abdominal pain (peptic ulcer)
- Odynophagia, gastroesophageal reflux, dysphagia (esophageal ulcer)
- Dysphagia, early satiety, unintentional weight loss, cachexia (malignancy)
Physical Exam
Physical exam should consist of a thorough abdominal exam for tenderness.
Investigations
Laboratory studies
- CBC
- Serum electrolytes
- Liver tests
- Coagulation panel
In patients at risk of MI, a ECG and cardiac enzymes are indicated.
Upper endoscopy
Following initial management, gastroenterological referral should be considered. Upper endoscopy has high sensitivity and specificity for finding and identifying lesions.