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.

HEMATEMESIS AND MELENA

HEMATEMESIS AND MELENA

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.

The major causes are illustrated on pages 261 and 262. 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. The 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. 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, etc.)
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)

Book Source Details

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

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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