Hematemesis
Encyclopedia
Hematemesis or haematemesis is the vomiting
of blood
. The source is generally the upper gastrointestinal tract
. Patients can easily confuse it with hemoptysis
(coughing up blood), although the latter is more common.
. The most vital distinction is whether there is blood loss sufficient to cause shock.
(e.g. omeprazole
), given blood transfusion
s (if the level of hemoglobin
is extremely low, that is less than 8.0 g/dL or 4.5-5.0 mmol/L), and kept NPO, which stands for "nil per os
" (Latin for "nothing by mouth", or no eating or drinking) until endoscopy
can be arranged. Adequate venous access (large-bore cannula
s or a central venous catheter
) is generally obtained in case the patient suffers a further bleed and becomes unstable.
. Fluids and/or blood is administered, preferably by central venous catheter, and the patient is prepared for emergency endoscopy, which is typically done in theatres. Surgical
opinion is usually sought in case the source of bleeding cannot be identified endoscopically, and laparotomy
is necessary.
Securing the airway is a top priority in hematemesis patients, especially those with a disturbed conscious level (hepatic encephalopathy in oesophageal varices patient.) A cuffed endotracheal tube could be a life saving choice.
Vomiting
Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...
of blood
Blood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....
. The source is generally the upper gastrointestinal tract
Gastrointestinal tract
The human gastrointestinal tract refers to the stomach and intestine, and sometimes to all the structures from the mouth to the anus. ....
. Patients can easily confuse it with hemoptysis
Hemoptysis
Hemoptysis or haemoptysis is the expectoration of blood or of blood-stained sputum from the bronchi, larynx, trachea, or lungs Hemoptysis or haemoptysis is the expectoration (coughing up) of blood or of blood-stained sputum from the bronchi, larynx, trachea, or lungs Hemoptysis or haemoptysis ...
(coughing up blood), although the latter is more common.
Signs
Signs of the onset of hematemesis may include:- A history of excessive alcohol useAlcohol abuseAlcohol abuse, as described in the DSM-IV, is a psychiatric diagnosis describing the recurring use of alcoholic beverages despite negative consequences. Alcohol abuse eventually progresses to alcoholism, a condition in which an individual becomes dependent on alcoholic beverages in order to avoid...
or liver diseaseLiver diseaseLiver disease is a broad term describing any single number of diseases affecting the liver.-Diseases:* Hepatitis, inflammation of the liver, caused mainly by various viruses but also by some poisons , autoimmunity or hereditary conditions... - Any esophago-gastric symptoms, such as nausea or vomiting
- Brown or black vomit
- Vomit that looks like coffee grounds
- Dark colored, tar-like stools (a condition known as melenaMelenaIn medicine, melena or melaena refers to the black, "tarry" feces that are associated with gastrointestinal hemorrhage. The black color is caused by oxidation of the iron in hemoglobin during its passage through the ileum and colon.-Melena vs...
)
Causes
Causes can be:- Prolonged and vigorous retchingRetchingRetching is a process in the human body where gastric contents are forced into the esophagus but do not enter the pharynx. Retching usually precedes vomiting, when the upper esophageal sphincter remains closed. If the upper esophageal sphincter is open, vomiting occurs. It can also be caused by a...
(may cause a tear in the small blood vessels of the throat or the esophagus, producing streaks of blood in the vomit, and is called Mallory-Weiss syndromeMallory-Weiss syndromeMallory–Weiss syndrome or gastro-esophageal laceration syndrome refers to bleeding from tears in the mucosa at the junction of the stomach and esophagus, usually caused by severe retching, coughing, or vomiting.-Causes:...
). - Irritation or erosion of the lining of the esophagusEsophagusThe esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
or stomachStomachThe stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is... - Bleeding ulcer located in the stomachStomachThe stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
, duodenumDuodenumThe duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms anterior intestine or proximal intestine may be used instead of duodenum...
, or esophagusEsophagusThe esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach... - VomitingVomitingVomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...
of ingested blood after hemorrhageBleedingBleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...
in the oral cavity, nose or throat - Vascular malfunctions of the gastrointestinal tractGastrointestinal tractThe human gastrointestinal tract refers to the stomach and intestine, and sometimes to all the structures from the mouth to the anus. ....
, such as bleeding gastric varicesGastric varicesGastric varices are dilated submucosal veins in the stomach, which can be a life-threatening cause of upper gastrointestinal hemorrhage. They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis...
or intestinal varicesIntestinal varicesIntestinal varices are dilated submucosal veins in the intestine.One treatment includes a transjugular intrahepatic portosystemic shunt.... - TumorTumorA tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...
s of the stomachStomachThe stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
or esophagus. - radiation poisoningRadiation poisoningAcute radiation syndrome also known as radiation poisoning, radiation sickness or radiation toxicity, is a constellation of health effects which occur within several months of exposure to high amounts of ionizing radiation...
- Viral hemorrhagic feverViral hemorrhagic feverThe viral hemorrhagic fevers are a diverse group of animal and human illnesses that are caused by four distinct families of RNA viruses: the families Arenaviridae, Filoviridae, Bunyaviridae, and Flaviviridae. All types of VHF are characterized by fever and bleeding disorders and all can progress...
s - GastroenteritisGastroenteritisGastroenteritis is marked by severe inflammation of the gastrointestinal tract involving both the stomach and small intestine resulting in acute diarrhea and vomiting. It can be transferred by contact with contaminated food and water...
- GastritisGastritisGastritis is an inflammation of the lining of the stomach, and has many possible causes. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs such as aspirin or ibuprofen. Sometimes gastritis develops after major surgery, traumatic...
- Peptic ulcerPeptic ulcerA peptic ulcer, also known as PUD or peptic ulcer disease, is the most common ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. It is defined as mucosal erosions equal to or greater than 0.5 cm...
- Chronic viral hepatitis
- Intestinal Schistosomiasis (caused by the parasite schistosoma mansoniSchistosoma mansoniSchistosoma mansoni is a significant parasite of humans, a trematode that is one of the major agents of the disease schistosomiasis. The schistosomiasis caused by Schistosoma mansoni is intestinal schistosomiasis....
) - History of SmokingSmokingSmoking is a practice in which a substance, most commonly tobacco or cannabis, is burned and the smoke is tasted or inhaled. This is primarily practised as a route of administration for recreational drug use, as combustion releases the active substances in drugs such as nicotine and makes them...
- Iatrogenic Injury (invasive procedure such as endoscopy or transesophageal echocardiography)
Management
Hematemesis is treated as a medical emergencyMedical emergency
A medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...
. The most vital distinction is whether there is blood loss sufficient to cause shock.
Minimal blood loss
If this is not the case, the patient is generally administered a proton pump inhibitorProton pump inhibitor
Proton-pump inhibitors are a group of drugs whose main action is a pronounced and long-lasting reduction of gastric acid production. They are the most potent inhibitors of acid secretion available today. The group followed and has largely superseded another group of pharmaceuticals with similar...
(e.g. omeprazole
Omeprazole
Omeprazole is a proton pump inhibitor used in the treatment of dyspepsia, peptic ulcer disease , gastroesophageal reflux disease , laryngopharyngeal reflux and Zollinger–Ellison syndrome...
), given blood transfusion
Blood transfusion
Blood transfusion is the process of receiving blood products into one's circulation intravenously. Transfusions are used in a variety of medical conditions to replace lost components of the blood...
s (if the level of hemoglobin
Hemoglobin
Hemoglobin is the iron-containing oxygen-transport metalloprotein in the red blood cells of all vertebrates, with the exception of the fish family Channichthyidae, as well as the tissues of some invertebrates...
is extremely low, that is less than 8.0 g/dL or 4.5-5.0 mmol/L), and kept NPO, which stands for "nil per os
Nil per os
Nil per os is a medical instruction meaning to withhold oral food and fluids from a patient for various reasons. It is a Latin phrase which translates as "nothing through the mouth". In the United Kingdom it is translated as nil by mouth .Typical reasons for NPO instructions are the prevention...
" (Latin for "nothing by mouth", or no eating or drinking) until endoscopy
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
can be arranged. Adequate venous access (large-bore cannula
Cannula
A cannula or canula is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of data...
s or a central venous catheter
Central venous catheter
In medicine, a central venous catheter is a catheter placed into a large vein in the neck , chest or groin...
) is generally obtained in case the patient suffers a further bleed and becomes unstable.
Significant blood loss
In a "hemodynamically significant" case of hematemesis, that is hypovolemic shock, resuscitation is an immediate priority to prevent cardiac arrestCardiac arrest
Cardiac arrest, is the cessation of normal circulation of the blood due to failure of the heart to contract effectively...
. Fluids and/or blood is administered, preferably by central venous catheter, and the patient is prepared for emergency endoscopy, which is typically done in theatres. Surgical
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
opinion is usually sought in case the source of bleeding cannot be identified endoscopically, and laparotomy
Laparotomy
A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...
is necessary.
Securing the airway is a top priority in hematemesis patients, especially those with a disturbed conscious level (hepatic encephalopathy in oesophageal varices patient.) A cuffed endotracheal tube could be a life saving choice.