Hematemesis
| Hematemesis | ||
| ICD-10 | K92.0 | |
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| ICD-9 | 578.0 | |
| DiseasesDB | 30745 | |
| eMedicine | med/3565 | |
| MeSH | C23.550.414.788.400 | |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editor-In-Chief: John Fani Srour, M.D.
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Overview
Hematemesis or haematemesis is the vomiting of blood. The source is generally the upper gastrointestinal tract (UGI). Patients can easily confuse it with hemoptysis (coughing up blood), although the former is more common. A nasogastric tube lavage that yields blood or coffee-ground like material confirms the diagnosis and predicts whether bleeding is caused by a high-risk lesion. The initial evaluation of the patient with UGI bleeding involves an assessment of hemodynamic stability and resuscitation if necessary. Upper endoscopy usually follows, with the goal of both diagnosis, and in some circumstances, treatment of the specific disorder. Important elements of the history include use of NSAIDs, alcohol, history of liver disease or variceal bleeding, history of ulcers, weight loss, dysphagia, or an abdominal aortic aneurysm (AAA). Any recent surgical procedure especially one involving the GI tract is also relevant. Endoscopic, clinical, and laboratory features are useful for risk stratification of patients who present with UGI bleeding. In addition, gastroenterology and surgical consultation are usually required, especially for high risk patients.
Significant Associated Signs and Symptoms
Associated symptoms and signs of hematemesis may include:
- Signs of liver disease (ascites, hepatomegaly, telangiectasia, etc)
- Signs of coagulopathy such as skin ecchemosis or hematuria
- signs of congential disease such as telangiectasias in hereditary hemorrhagic telangiectasia
- Any esophogastric symptoms, such as nausea or vomiting
- Dark colored, tar like stools (a condition known as melena)
- Symptoms of weight loss, early satiety, or loss of appetite raise suspicions for malignant process.
Complete Differential Diagnosis of the Causes of Hematemesis
(In alphabetical order)
- Abciximab
- Acute esophageal necrosis (AEN)
- Adenocarcinoma
- Alendronate induced esophagitis
- Angiodysplasia
- Angioma
- Aortic Coarctation
- Aortoenteric fistula
- Arterial, venous, or other vascular malformations
- Aspirin induced ulcers or gastritis
- Blue rubber bleb nevus syndrome
- Candida albicans esophagitis
- Carcinoid tumors in the stomach
- Caustic ingestion
- Clopidogrel
- Coagulopathy
- Congenital malformations
- Coumadin
- Cow's milk allergy is a significant reason for haematemesis in newborns
- Crimean-Congo hemorrhagic fever
- Cytomegalovirus esophagitis
- Dieulafoy's lesion
- Disseminated intravascular coagulation
- Drotrecogin alfa
- Drug-induced thrombocytopenia
- Duodenal varices
- Duplication cysts
- Ehlers-Danlos syndrome
- Esophageal cancer
- Esophageal dilatation (iatrogenic)
- Esophageal melanosis
- Esophagitis
- Foreign body ingestion especially in children
- Gastric varices
- Helicobacter pylorirelated gastritis or peptic ulcer disease
- Hemobilia
- Hemophilia
- Hemosuccus pancreaticus
- Heparin
- Hereditary hemorrhagic telangiectasia
- Herpes simplex virus esophagitis
- Heterotopic pancreatic tissue
- Idiopathic
- Idiopathic thrombocytopenic purpura
- Intestinal duplication a cause of haematemesis in children
- Kaposi's sarcoma
- Kasabach-Merritt syndromes
- Leiomyoma
- Lipoma
- Lymphoma
- Mallory-Weiss syndrome
- Melanoma
- Metastatic tumor to the upper GI tract
- Munchausen syndrome by proxy a reason for recurrent haemetmesis in children
- Nonsteroidal antiinflammatory drugs
- Osler-Weber-Rendu syndrome
- Parasites
- Peptic ulcer disease
- Pill-induced esophagitis
- Polyp (hyperplastic, adenomatous, hamartomatous, etc)
- Portal hypertension
- Portal hypertensive gastropathy
- Post gastric/duodenal polypectomy
- Post-surgical anastamosis
- Potassium chloride induced esophagitis or gastritis
- Pseudomembranous esophagitis
- Quinidine
- Radiation-induced telangiectasia
- Rift valley fever
- Schistosomiasis
- Sibutramine
- Stress-induced ulcer
- Systemic mastocytosis
- Tetracycline (pill induced esophagitis)
- Ticlopidine
- Traumatic or post-surgical
- Vasculitis
- Von Willebrand disease
- Watermelon stomach (gastric antral vascular ectasia)
- Zollinger Ellison syndrome ( diffuse upper GI ulcerations)
Complete Differential Diagnosis of the Causes of Hematemesis
(By organ system)
| Cardiovascular | Arterial, venous, or other vascular malformations, Idiopathic angiomas, Dieulafoy's lesion, Angiodysplasia, Aortic Coarctation, Aortoenteric fistula |
| Chemical / poisoning | Caustic ingestion |
| Dermatologic | No underlying causes |
| Drug Side Effect | Abciximab, Aspirin, Clopidogrel , Tetracycline (pill induced esophagitis), Ticlopidine, Quinidine, Drotrecogin alfa, Heparin, Coumadin, Alendronate, Tetracycline, Quinidine, Potassium chloride, Nonsteroidal antiinflammatory drugs, |
| Ear Nose Throat | No underlying causes |
| Endocrine | No underlying causes |
| Environmental | No underlying causes |
| Gastroenterologic | Portal hypertension, Esophageal varices, Gastric varices, Duodenal varices, Portal hypertensive gastropathy, Acute esophageal necrosis (AEN), Pseudomembranous esophagitis, Watermelon stomach (gastric antral vascular ectasia), Mallory-Weiss tear, Aortoenteric fistula, Carcinoid, Cow's milk allergy, Dieulafoy's lesion, Esophageal cancer, Esophageal dilatation, Esophageal melanosis, Esophagitis, Helicobacter pylori, Hemobilia, Hemosuccus pancreaticus, Hereditary hemorrhagic telangiectasia, Heterotopic pancreatic tissue, Intestinal duplication, Parasites, Schistosomiasis |
| Genetic | Duplication cysts, Ehlers-Danlos syndrome, Hereditary hemorrhagic telangiectasia, Osler-Weber-Rendu syndrome, Intestinal duplication |
| Hematologic | Ticlopidine, Clopidogrel, Hemophilia, Drug-induced thrombocytopenia, Von Willebrand disease, Idiopathic thrombocytopenic purpura, Coagulopathy, Disseminated intravascular coagulation, Drotrecogin alfa, Osler-Weber-Rendu syndrome |
| Iatrogenic | Radiation-induced telangiectasia, Traumatic or post-surgical, Mallory-Weiss tear, Foreign body ingestion, pill induced esophagitis, Post-surgical anastamosis
Aortoenteric fistula, Post gastric/duodenal polypectomy, Munchausen syndrome by proxy, Caustic ingestion, Esophageal dilatation, Foreign body ingestion |
| Infectious Disease | Helicobacter pylori, Cytomegalovirus, Herpes simplex virus, Candida albicans, Parasites, Crimean-Congo hemorrhagic fever, Schistosomiasis |
| Musculoskeletal / Ortho | No underlying causes |
| Neurologic | No underlying causes |
| Nutritional / Metabolic | No underlying causes |
| Obstetric/Gynecologic | No underlying causes |
| Oncologic | Leiomyoma, Lipoma, Polyp (hyperplastic, adenomatous, hamartomatous),
Adenocarcinoma, Lymphoma, Kaposi's sarcoma, Carcinoid, Melanoma, Metastatic tumor, Kasabach-Merritt syndromes, Systemic mastocytosis, Zollinger Ellison syndrome, |
| Opthalmologic | No underlying causes |
| Overdose / Toxicity | No underlying causes |
| Psychiatric | Munchausen syndrome by proxy, Stress-induced ulcer, |
| Pulmonary | No underlying causes |
| Renal / Electrolyte | No underlying causes |
| Rheum / Immune / Allergy | Cow's milk allergy, Vasculitis |
| Sexual | No underlying causes |
| Trauma | No underlying causes |
| Urologic | No underlying causes |
| Miscellaneous | Heterotopic pancreatic tissue |
Management
Individuals who are at low risk for recurrent or life-threatening hemorrhage may be suitable for early hospital discharge or even outpatient care. All patients with hemodynamic instability or active bleeding should be admitted to an intensive care unit for resuscitation and close observation. Two large caliber peripheral catheters or a central venous line should be inserted for intravenous access. Gastroenterological consultation should be obtained. A surgical consultation can be obtained in high-risk patients. These patients should also receive packed red blood cell transfusions to maintain the hematocrit above 30 percent. In general, patients with upper GI bleeding ( high and low risk) should be treated with an intravenous PPI at presentation until confirmation of the cause of bleeding, after which the need for specific therapy can be determined. Patients known to have cirrhosis who present with upper GI bleeding receive antibiotics, preferably before endoscopy, as bacterial infections are present in up to 20 percent of these patients. Somatostatin may also reduce the risk of bleeding due to variceal and nonvariceal causes.
Prophylaxis
- Primary prophylaxis against variceal hemorrhage is indicated because of high rate of bleeding from esophageal varices and the high mortality associated with bleeding. Prophylactic propranolol or nadolol therapy is the only cost-effective therapy in this setting.
- Prophylaxis against stress ulceration maybe also indicated for ICU patients with any of the following characteristics:
- Coagulopathy
- Mechanical ventilation for more than 2 days
- History of GI ulceration or bleeding with the past year
- Two or more of the following risk factors — sepsis, ICU admission lasting >1 week, occult GI bleeding lasting ≥6 days, and glucocorticoid therapy.
- Effective identification and antibiotic treatment of H.Pylori infections is also crutial in preventing complications including upper GI bleeding.
- In regards to prevention of NSAID related peptic ulcer disease and related upper GI bleed: patients with some risk factors are at highest risk for NSAID-induced GI toxicity A history of an ulcer or GI hemorrhage increases risk four- to fivefold
Age >60 increases risk five- to sixfold High (more than twice the customary) dosage of a NSAID increases risk 10-fold Concurrent use of glucocorticoids increases risk four to fivefold Concurrent use of anticoagulants increases risk up to 15-fold (see "Therapeutic use of warfarin" section on bleeding) (up to 9 percent after six months of NSAID exposure) [4,5].
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