Hematemesis

Hematemesis is the medical term for vomiting blood, and it is a potentially serious symptom that requires prompt evaluation and management in the emergency department (ED). As a junior doctor, understanding the causes, assessment, and management of hematemesis is crucial for providing effective patient care.

Understanding Hematemesis

Hematemesis involves the expulsion of blood from the upper gastrointestinal (GI) tract, which includes the esophagus, stomach, and duodenum. The vomited blood may appear bright red or have a "coffee ground" appearance, indicating partial digestion by stomach acid.

Common Causes of Hematemesis

Peptic Ulcer Disease

• Ulcers in the stomach or duodenum can erode into blood vessels, leading to bleeding. Common risk factors include Helicobacter pylori infection and nonsteroidal anti-inflammatory drug (NSAID) use.

Esophageal Varices

• These are dilated veins in the esophagus, often due to portal hypertension from liver cirrhosis. Variceal bleeding can be massive and life-threatening.

Gastritis or Esophagitis

• Inflammation of the stomach lining or esophagus can cause bleeding, often related to NSAID use, alcohol consumption, or gastroesophageal reflux disease (GERD).

Mallory-Weiss Tear

• A tear at the gastroesophageal junction caused by severe retching or vomiting can lead to hematemesis.

Less Common Causes

• Malignancies of the stomach or esophagus

• Vascular malformations

• Swallowed blood from epistaxis (nosebleed)

Initial Assessment and Management

History Taking

A thorough history is essential to guide further evaluation:

• Onset and amount of bleeding

• Associated symptoms such as abdominal pain, melena (black tarry stools), or syncope

• History of liver disease, alcohol use, or NSAID use

• Previous episodes of GI bleeding or known ulcers

Physical Examination

The physical examination should focus on identifying signs that may indicate specific causes:

• Vital signs: Assess for hypotension and tachycardia indicating hemodynamic instability.

• Abdominal examination: Evaluate for tenderness, distension, or signs of liver disease such as ascites.

• Skin examination: Look for signs of chronic liver disease like jaundice or spider angiomas.

Diagnostic Workup

Depending on clinical suspicion from history and examination, the following tests may be considered:

• Complete Blood Count (CBC): To assess for anemia.

• Coagulation Profile: To evaluate clotting status.

• Liver Function Tests: If liver disease is suspected.

• Blood Type and Crossmatch: In case transfusion is needed.

• Upper Endoscopy: To directly visualize and potentially treat the source of bleeding.

Management Strategies

Management of hematemesis in the ED focuses on stabilization and addressing the underlying cause:

1. Stabilization:

   • Ensure airway protection if there is a risk of aspiration.

   • Establish intravenous access for fluid resuscitation with crystalloids.

   • Transfuse packed red blood cells if there is significant anemia or hemodynamic instability.

2. Specific Interventions:

   • Administer proton pump inhibitors (PPIs) intravenously for suspected peptic ulcer bleeding.

   • Consider octreotide infusion and antibiotics for suspected variceal bleeding.

   • Urgent endoscopy for diagnosis and treatment (e.g., banding of varices or cauterization of ulcers).

3. Monitoring and Follow-up:

   • Continuous monitoring in a high-dependency area for recurrent bleeding.

   • Referral to gastroenterology for further management after stabilization.

Challenges and Considerations

Hematemesis can be life-threatening due to potential massive blood loss. Rapid identification and intervention are crucial to prevent complications such as shock. It is important to differentiate between upper GI bleeding (hematemesis) and lower GI bleeding (hematochezia or melena) based on clinical presentation.

By taking a systematic approach to the assessment and management of hematemesis, you can effectively address this condition in the emergency setting while ensuring appropriate follow-up care.