HEMATEMESIS AND MELENA

Hematemesis means vomiting or regurgitation of frank bright red blood or coffee-ground material that is positive for occult blood. It may be differentiated from hemoptysis because it usually gives an acidic reaction to nitrazine paper. It may be swallowed blood from any site in the oral cavity or nasopharynx, thus careful examination of these areas must be done. The differential of hematemesis, like that for bleeding from other body orifices, is best developed with the use of anatomy. Thus, beginning with the esophagus and working down to the ligament of Treitz and at the same time cross-indexing each structure with the various etiologies, one can make a chart like Table 34.

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HEMATEMESIS AND MELENA

	V	I	N	D
	Vascular	Inflammatory	Neoplasm	Degenerative
				and Deficiency
Esophagus	Esophageal varices Aortic aneurysm	Reflux esophatitis Ulcer Trypanosomiasis cruzi	Carcinomas of esophagus and lung
Stomach	Cardiac varices Ruptured aneurysm	Gastritis Gastric ulcer	Carcinoma	Atrophic gastritis
Duodenum		Ulcer
Pancreas		Acute pancreatitis (hemorrhagic)
Blood			Leukemia Polycythemia	Aplastic anemia Vitamin K deficiency

ITP, idiopathic thrombocytopenic purpura.

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HAND AND FINGER PAIN

I	C	A	T	E
Intoxication	Congenital	Autoimmune	Trauma	Endocrine
		Allergic
Lye and other irritants Foreign body	Hiatal hernia Esophagitis	Scleroderma	Foreign body Nasogastric tube Mallory–Weiss syndrome
Alcoholic gastritis, aspirin, and other drugs (e.g., arsenic)	Hereditary telangiectasis		Perforation and laceration surgery	Zollinger–Ellison syndrome
		Regional ileitis	Perforation and laceration surgery	Zollinger–Ellison syndrome
Warfarin Heparin Other drugs	Hemophilia and other hereditary coagulation disorders	ITP Collagen disease and other causes of thrombocytopenia

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The major causes are illustrated on pages 215 and 218. In the esophagus the most common causes are varices, reflux esophagitis, carcinoma, and the Mallory–Weiss syndrome. One should not forget foreign bodies or irritants such as lye, especially in children. Barrett esophagitis and ulcers caused by ectopic gastric mucosa are rare congenital causes of hematemesis. Finally, aortic aneurysms, mediastinal tumors, and carcinomas of the lung may ulcerate through the esophagus and bleed. In the stomach, inflammation, especially gastritis and ulcers, is a prominent cause. Aspirin or alcohol, however, is often the cause. Varices of the cardia of the stomach may bleed. Carcinomas and hereditary telangiectasis are less common causes. Duodenal ulcers are usually the cause of bleeding from the duodenum, but occasionally neoplasms and regional ileitis may be involved. Ulceration of gallstones through the gallbladder and duodenal wall is another rare cause of bleeding from this site. The pancreas is included in the drawing because occasionally one encounters gross hematemesis during acute hemorrhagic pancreatitis when blood pours out of the duct and is vomited. Trauma is an important cause of bleeding from all the aforementioned sites, especially following intubation or surgery. Blood dyscrasias associated with coagulation disorders should be looked for immediately whenever a focal cause of hematemesis cannot be found, especially if bleeding is massive.

Approach to the Diagnosis

When confronted with solid evidence of hematemesis, the clinician should not waste valuable time on a thorough history and physical examination when endoscopy is more important in both diagnosis and therapy. Ordering a type and cross for multiple units of blood, coagulation studies, and the other tests listed below should also be done immediately in most cases. History of alcoholism, use of aspirin and other drugs, and previous ulcers or esophageal disease is important to get while preparing for endoscopy and other emergency procedures. Patients without massive or recent acute hematemesis may be approached with traditional methods. A history of vomiting nonhemorrhagic gastric fluid before the onset of hematemesis is helpful in diagnosing a Mallory–Weiss syndrome.

Other Useful Tests

1. Complete blood count (CBC) (anemia of blood loss)
2. Chemistry panel (liver disease, kidney disease)
3. Stool for occult blood (ulcer, neoplasm, diverticulitis)
4. Gastric analysis (ulcer, neoplasm)
5. Liver function tests (esophageal varices)
6. Upper GI series and esophagram (reflux esophagitis, ulcer, esophageal carcinoma, gastric carcinoma)
7. Coagulation studies (blood dyscrasias, hemophilia, e.g.)
8. Barium enema (colon neoplasm, diverticulitis)
9. Small-bowel series (neoplasm, diverticulitis)
10. CT scan of abdomen (neoplasm)
11. Colonoscopy (colon neoplasm. bleeding diverticulum)
12. Arteriogram (mesenteric thrombosis)
13. Fluorescein dye string test (to determine site of occult bleeding)
14. Nuclear scan (to detect bleeding)
15. Breath test and stool antigen for Helicobacter pylori (peptic ulcer)

CASE PRESENTATION #41 A 36-year-old black woman is brought to the emergency room with a chief complaint of hematemesis. She denies any previous episodes of hematemesis and only drinks on social occasions.

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Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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