Diseases » Cyclic vomiting syndrome

Hematemesis

Hematemesis: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)

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. Swallowed blood from epistaxis or oropharyngeal erosion may also cause bloody vomitus. Hematemesis may be precipitated by straining, emotional stress, and the use of anti-inflammatory drugs or alcohol. In a patient with esophageal varices, hematemesis may be due to trauma from swallowing hard or partially chewed food. (See Rare causes of hematemesis.)

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

Emergency interventions

If the patient has massive hematemesis, check his vital signs. If you detect signs of shock—such as tachypnea, hypotension, and tachycardia—place the patient in a supine position, and elevate his feet 20 to 30 degrees. Start a large-bore I.V. line for emergency fluid replacement. Also, obtain 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, page 404.)

History and physical examination

If 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.

Begin the physical examination by checking for orthostatic hypotension, an early warning sign of hypovolemia. Take blood pressure and pulse with the patient in the 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

Achalasia

Hematemesis is a rare effect of this disorder, which usually causes passive regurgitation and painless, progressive dysphagia. Regurgitation of undigested food may cause hoarseness, coughing, aspiration, and recurrent pulmonary infections.

Anthrax, GI

GI anthrax is caused by eating meat contaminated with the gram-positive, spore-forming bacterium Bacillus anthracis. Initial signs and symptoms of anorexia, nausea, vomiting, and fever may progress to hematemesis, abdominal pain, and severe bloody diarrhea.

Coagulation disorders

Any disorder that disrupts normal clotting, such as thrombocytopenia or hemophilia, 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. Associated effects depend on the specific coagulation disorder.

Esophageal cancer

A late sign of this 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 alkalies 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

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 and 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 this uncommon cancer, which usually begins insidiously with upper abdominal discomfort. The patient then develops anorexia, mild nausea, and chronic dyspepsia that’s 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 another NSAID. Gastritis may also occur secondary to Helicobacter pylori infection.

Gastroesophageal reflux disease

Although rare in this disorder, hematemesis may produce significant blood loss. It’s accompanied by pyrosis, flatulence, dyspepsia, and postural regurgitation that can be aggravated by lying down or stooping over. Related effects include dysphagia, retrosternal angina-like chest pain, weight loss, halitosis, and signs of aspiration, such as dyspnea and recurrent pulmonary infections.

Leiomyoma

This benign tumor 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, this syndrome may produce hematemesis and melena. It’s commonly triggered by severe vomiting, retching, or straining (as from coughing), usually 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. Some 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 very frightening. Administer a histamine-2 blocker I.V.; vasopressin may be required for ruptured esophageal varices. 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 hepatic 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.

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Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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