Vomiting blood

Introduction

Vomiting blood, medically known as hematemesis, is the expulsion of blood from the mouth following bleeding in the upper gastrointestinal (GI) tract, typically proximal to the ligament of Treitz (esophagus, stomach, duodenum). It is a medical emergency requiring immediate evaluation and treatment, as it may signal life-threatening pathology such as peptic ulcer disease, variceal bleeding, or malignancy.

Hematemesis may present as:

• Fresh bright red blood: Suggests active bleeding, often esophageal or gastric.

• Coffee-ground vomitus: Indicates slower or less severe bleeding, as blood has been partially digested by gastric acid.

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Causes of Vomiting Blood

1. Esophageal Causes

• Esophageal varices: Dilated veins due to portal hypertension (e.g., in cirrhosis).

• Esophagitis: Inflammation from GERD, infection, or pills.

• Mallory-Weiss tear: Longitudinal mucosal tear at the gastroesophageal junction due to severe vomiting or retching.

• Esophageal cancer.

2. Gastric Causes

• Peptic ulcer disease (PUD): Gastric or duodenal ulcers eroding into vessels.

• Gastritis: Erosive gastritis (NSAIDs, alcohol, stress-related).

• Gastric cancer or polyps.

• Dieulafoy’s lesion: Large caliber artery in the stomach wall prone to rupture.

3. Duodenal Causes

• Duodenal ulcers.

• Angiodysplasia or vascular malformations.

4. Systemic and Iatrogenic Causes

• Anticoagulant therapy (warfarin, DOACs).

• Platelet dysfunction or thrombocytopenia.

• Hemorrhagic disorders (hemophilia, liver failure).

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Clinical Presentation

• Hematemesis: Fresh red or coffee-ground blood in vomit.

• Associated features:

  • Melena (black tarry stools): Suggests ongoing upper GI bleeding.

  • Hematochezia (fresh blood in stools): Rare, only with massive upper GI bleeding.

  • Symptoms of hypovolemia: Dizziness, syncope, tachycardia, hypotension.

  • Underlying liver disease: Jaundice, ascites, spider angiomas in variceal bleeds.

  • Preceding retching: Points to Mallory-Weiss tear.

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Diagnosis

1. Initial Assessment

• Airway, Breathing, Circulation (ABC).

• Vital signs: blood pressure, heart rate, oxygen saturation.

2. Laboratory Tests

• CBC: Hemoglobin, hematocrit, platelets.

• Coagulation profile: INR, PT, aPTT.

• Liver function tests: To assess cirrhosis/portal hypertension.

• Urea/creatinine: Urea often elevated after GI bleed.

• Blood type and crossmatch: Prepare for transfusion.

3. Imaging and Procedures

• Nasogastric aspiration: To confirm ongoing bleeding (rarely used now).

• Upper GI Endoscopy (Esophagogastroduodenoscopy, EGD): Gold standard for diagnosis and treatment.

• CT angiography: If endoscopy fails to locate source.

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Treatment

1. Immediate Stabilization

• Airway protection: Especially in massive hematemesis or altered consciousness.

• IV access (large bore cannulas): For fluids and blood transfusion.

• Fluid resuscitation: Normal saline or Ringer’s lactate.

• Blood transfusion: If Hb < 7 g/dL (target 7–9 g/dL, higher in cardiac patients).

• Correction of coagulopathy: Fresh frozen plasma, vitamin K, platelet transfusion if needed.

2. Pharmacological Therapy

a) Proton Pump Inhibitors (PPIs) – for peptic ulcer bleeding

• Omeprazole IV: 80 mg bolus, then 8 mg/hour infusion for 72 hours.

• Pantoprazole IV: Same regimen.

• Reduces risk of rebleeding and promotes clot stability.

b) Variceal Bleeding (Cirrhosis/Portal Hypertension)

• Vasopressin analogs:

  • Terlipressin IV: 2 mg every 4–6 hours.

• Somatostatin analogs:

  • Octreotide IV infusion: 50 μg bolus, then 50 μg/hour infusion.

• Prophylactic antibiotics:

  • Ceftriaxone 1 g IV daily for 7 days (reduces mortality in cirrhotic patients).

c) Mallory-Weiss Tear

• Often self-limiting; PPIs and supportive care.

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3. Endoscopic Therapy (First-Line Definitive Treatment)

Performed urgently (within 24 hours, or immediately if unstable).

• Endoscopic injection therapy: Epinephrine injection.

• Thermal coagulation: Heat probe, argon plasma coagulation.

• Mechanical therapy: Endoscopic clips or band ligation (especially for varices).

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4. Surgical and Radiological Interventions

• Transjugular intrahepatic portosystemic shunt (TIPS): For refractory variceal bleeding.

• Surgery: Rare, reserved for uncontrolled bleeding after failed endoscopy.

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Precautions

• Avoid NSAIDs and aspirin unless absolutely necessary.

• Monitor closely for rebleeding during first 72 hours.

• Correct underlying liver disease and portal hypertension if present.

• In variceal bleeding, beta-blockers (Propranolol 20–40 mg twice daily) are prescribed long-term to prevent recurrence.

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Drug Interactions

• PPIs + Clopidogrel: Reduced activation of clopidogrel (use pantoprazole if needed).

• Terlipressin + Beta-blockers: Risk of severe bradycardia and hypotension.

• Octreotide + Insulin/antidiabetics: Alters glucose regulation.

• Warfarin/DOACs + NSAIDs: Greatly increased GI bleeding risk.

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Red-Flag Features Requiring Urgent Hospitalization

• Hematemesis with shock (low BP, tachycardia, collapse).

• Altered consciousness or risk of aspiration.

• Known cirrhosis with variceal bleeding.

• Severe anemia (Hb < 7 g/dL).

• Ongoing bleeding despite resuscitation.

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Long-Term Management and Prevention

• Peptic ulcer disease: Test and treat Helicobacter pylori (Triple therapy: Omeprazole 20 mg + Clarithromycin 500 mg + Amoxicillin 1 g, all twice daily for 14 days).

• Cirrhosis/varices:

  • Non-selective beta-blockers (Propranolol or Nadolol).

  • Endoscopic variceal band ligation at intervals.

• Lifestyle: Avoid alcohol, NSAIDs, smoking.

• Regular follow-up endoscopy in high-risk patients.