Hematemesis

Hematemesis: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses

Hematemesis, the vomiting of blood, usually indicates GI bleeding above the ligament of Treitz, which suspends the duodenum at its junction with the jejunum. Bright red or blood-streaked vomitus indicates fresh or recent bleeding. Dark red, brown, or black vomitus (the color and consistency of coffee grounds) indicates that blood has been retained in the stomach and partially digested.

Although hematemesis usually results from a GI disorder, it may stem from a coagulation disorder or from a treatment that irritates the GI tract. Esophageal varices may also cause hematemesis. Swallowed blood from epistaxis or oropharyngeal erosion may also cause bloody vomitus. Hematemesis may be precipitated by straining, emotional stress, and the use of an anti-inflammatory or alcohol. In a patient with esophageal varices, hematemesis may be a result of trauma from swallowing hard or partially chewed food.

Hematemesis is always an important sign, but its severity depends on the amount, source, and rapidity of the bleeding. Massive hematemesis (vomiting of 500 to 1,000 ml of blood) may be life-threatening.

Emergency Actions

If the patient has massive hematemesis, check his vital signs. If you detect signs of shock — such as tachypnea, hypotension, and tachycardia — place him in a supine position, and elevate his feet 20 to 30 degrees. Start a large-bore I.V. line for emergency fluid replacement. Also, send a blood sample for typing and crossmatching, hemoglobin level, and hematocrit, and administer oxygen. Emergency endoscopy may be necessary to locate the source of bleeding. Prepare to insert a nasogastric (NG) tube for suction or iced lavage. A Sengstaken-Blakemore tube may be used to compress esophageal varices. (See Managing hematemesis with intubation.)

History

If the patient’s hematemesis isn’t immediately life-threatening, begin with a thorough history. First, have the patient describe the amount, color, and consistency of the vomitus. When did he first notice this sign? Has he ever had hematemesis before? Find out if he also has bloody or black, tarry stools. Note whether hematemesis is usually preceded by nausea, flatulence, diarrhea, or weakness. Has he recently had bouts of retching with or without vomiting?

Next, ask about a history of ulcers or of liver or coagulation disorders. Find out how much alcohol the patient drinks, if any. Does he regularly take aspirin or another nonsteroidal anti-inflammatory drug (NSAID), such as phenylbutazone or indomethacin? These drugs may cause erosive gastritis or ulcers.

Physical assessment

Begin the physical examination by checking for orthostatic hypotension, an early warning sign of hypovolemia. Take blood pressure and pulse with the patient in supine, sitting, and standing positions. A decrease of 10 mm Hg or more in systolic pressure or an increase of 10 beats/minute or more in pulse rate indicates volume depletion. After obtaining other vital signs, inspect the mucous membranes, nasopharynx, and skin for any signs of bleeding or other abnormalities. Finally, palpate the abdomen for tenderness, pain, or masses. Note lymphadenopathy.

Medical causes

Anthrax (GI)

With GI anthrax, initial signs and symptoms, including loss of appetite, nausea, vomiting, and fever, appear after eating contaminated meat from an animal infected with the gram-positive, spore-forming bacterium Bacillus anthracis. Signs and symptoms may progress to hematemesis, abdominal pain, and severe bloody diarrhea.

Coagulation disorders

Any disorder that disrupts normal clotting may result in GI bleeding and moderate to severe hematemesis. Bleeding may occur in other body systems as well, resulting in such signs as epistaxis and ecchymosis. Other associated effects vary, depending on the specific coagulation disorder, such as thrombocytopenia or hemophilia.

Esophageal cancer

A late sign of esophageal cancer, hematemesis may be accompanied by steady chest pain that radiates to the back. Other features include substernal fullness, severe dysphagia, nausea, vomiting with nocturnal regurgitation and aspiration, hemoptysis, fever, hiccups, sore throat, melena, and halitosis.

Esophageal injury by caustic substances

Ingestion of corrosive acids or alkalis produces esophageal injury associated with grossly bloody or coffee-ground vomitus. Hematemesis is accompanied by epigastric and anterior or retrosternal chest pain that’s intensified by swallowing. With ingestion of alkaline agents, the oral and pharyngeal mucosa may produce a soapy white film. The mucosa becomes brown and edematous with time. Dysphagia, marked salivation, and fever may develop in 3 to 4 weeks and worsen as strictures form.

Esophageal rupture

With esophageal rupture, the severity of hematemesis depends on the cause of the rupture. When an instrument damages the esophagus, hematemesis is usually slight. However, rupture due to Boerhaave’s syndrome (increased esophageal pressure from vomiting or retching) or other esophageal disorders typically causes more severe hematemesis. This life-threatening disorder may also produce severe retrosternal, epigastric, neck, or scapular pain accompanied by chest and neck edema. Examination reveals subcutaneous crepitation in the chest wall, supraclavicular fossa, and neck. The patient may also show signs of respiratory distress, such as dyspnea and cyanosis.

Esophageal varices (ruptured)

Life-threatening rupture of esophageal varices may produce coffee-ground or massive, bright red vomitus. Signs of shock, such as hypotension or tachycardia, may follow or even precede hematemesis if the stomach fills with blood before vomiting occurs. Other symptoms may include abdominal distention and melena or painless hematochezia, ranging from slight oozing to massive rectal hemorrhage.

Gastric cancer

Painless bright red or dark brown vomitus is a late sign of gastric cancer, an uncommon cancer that usually begins insidiously with upper-abdominal discomfort. The patient then develops anorexia, mild nausea, and chronic dyspepsia unrelieved by antacids and exacerbated by food. Later symptoms may include fatigue, weakness, weight loss, feelings of fullness, melena, altered bowel habits, and signs of malnutrition, such as muscle wasting and dry skin.

Gastritis (acute)

Hematemesis and melena are the most common signs of acute gastritis. They may even be the only signs, although mild epigastric discomfort, nausea, fever, and malaise may also occur. Massive blood loss precipitates signs of shock. Typically, the patient has a history of alcohol abuse or has used aspirin or some other NSAID. Gastritis may also occur secondary to Helicobacter pylori infection.

GI leiomyoma

GI leiomyoma is a benign tumor that occasionally involves the GI tract, eroding the mucosa or vascular supply to produce hematemesis. Other features vary with the tumor’s size and location. For example, esophageal involvement may cause dysphagia and weight loss.

Mallory-Weiss syndrome

Characterized by a mucosal tear of the mucous membrane at the junction of the esophagus and the stomach, Mallory-Weiss syndrome may produce hematemesis and melena. It’s commonly triggered by severe vomiting, retching, or straining (as from coughing), most commonly in alcoholics or in people whose pylorus is obstructed. Severe bleeding may precipitate signs of shock, such as tachycardia, hypotension, dyspnea, and cool, clammy skin.

Peptic ulcer

Hematemesis may occur when a peptic ulcer penetrates an artery, vein, or highly vascular tissue. Massive — and possibly life-threatening — hematemesis is typical when an artery is penetrated. Other features include melena or hematochezia, chills, fever, and signs and symptoms of shock and dehydration, such as tachycardia, hypotension, poor skin turgor, and thirst. Most patients have a history of nausea, vomiting, epigastric tenderness, and epigastric pain that’s relieved by foods or antacids. The patient may also have a history of habitual use of tobacco, alcohol, or NSAIDs.

Other causes

Treatments

Traumatic NG or endotracheal intubation may cause hematemesis associated with swallowed blood. Nose or throat surgery may also cause this sign in the same way.

Special considerations

Closely monitor the patient’s vital signs, and watch for signs of shock. Check the patient’s stools regularly for occult blood, and keep accurate intake and output records. Place the patient on bed rest in a low or semi-Fowler’s position to prevent aspiration of vomitus. Keep suctioning equipment nearby, and use it as needed. Provide frequent oral hygiene and emotional support — the sight of bloody vomitus can be extremely frightening. Administer a histamine-2 blocker I.V.; vasopressin may be required for variceal hemorrhage. As the bleeding tapers off, monitor the pH of gastric contents, and give hourly doses of antacids by NG tube as necessary.

Pediatric pointers

Hematemesis is much less common in children than in adults and may be related to foreign-body ingestion. Occasionally, neonates develop hematemesis after swallowing maternal blood during delivery or breast-feeding from a cracked nipple. Hemorrhagic disease of the neonate and esophageal erosion may also cause hematemesis in infants; such cases require immediate fluid replacement.

Geriatric pointers

In elderly patients, hematemesis may be caused by a vascular anomaly, an aortoenteric fistula, or upper GI cancer. In addition, chronic obstructive pulmonary disease, chronic liver or renal failure, and chronic NSAID use all predispose elderly people to hemorrhage secondary to coexisting ulcerative disorders.

Patient counseling

Explain diagnostic tests, such as endoscopy, barium swallow, and variceal banding. Explain laboratory tests, such as serum electrolyte levels, complete blood count, prothrombin time, partial thromboplastin time, and International Normalized Ratio. Discuss food or fluid restrictions as needed.

Pictures

Book Source Details

• Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1

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