Diagnostic Approach to Hematemesis: What Every Doctor Should Know

Hematemesis, the vomiting of blood, is a critical symptom that can indicate severe underlying pathology, ranging from benign conditions to life-threatening emergencies. For medical students and healthcare professionals, the assessment of hematemesis is a vital skill, requiring a thorough understanding of its causes, diagnostic approach, and management strategies. This article provides an in-depth guide on how to assess hematemesis, offering practical insights and evidence-based recommendations.

Understanding Hematemesis

Hematemesis refers to the expulsion of blood through vomiting, which can be bright red or resemble coffee grounds, depending on the extent of blood digestion by gastric acid. The blood typically originates from the upper gastrointestinal (GI) tract, which includes the esophagus, stomach, and duodenum. The differentiation between hematemesis and other forms of GI bleeding, such as hematochezia or melena, is crucial for accurate diagnosis and treatment.

Common Causes of Hematemesis

1. Peptic Ulcer Disease (PUD):
   • The most common cause of hematemesis, PUD results from mucosal damage in the stomach or duodenum due to excess acid production, Helicobacter pylori infection, or the use of nonsteroidal anti-inflammatory drugs (NSAIDs).
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5757759/
2. Esophageal Varices:
   • These are dilated submucosal veins in the esophagus, often a consequence of portal hypertension due to liver cirrhosis. Rupture of varices can lead to massive, life-threatening bleeding.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4043528/
3. Gastritis:
   • Inflammation of the gastric mucosa can lead to bleeding, particularly when associated with erosions or ulcers. Causes include alcohol consumption, stress, infections, and certain medications.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3080811/
4. Mallory-Weiss Tear:
   • This refers to a mucosal laceration at the gastroesophageal junction, typically resulting from forceful vomiting or retching, leading to hematemesis.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011544/
5. Gastroesophageal Reflux Disease (GERD):
   • Although less common, severe GERD can cause bleeding due to erosive esophagitis.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6691597/
6. Neoplasms:
   • Tumors in the stomach or esophagus, whether benign or malignant, can cause bleeding, leading to hematemesis.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7724695/
7. Dieulafoy’s Lesion:
   • This rare condition involves a large, tortuous arteriole in the stomach wall that erodes and bleeds into the gastric lumen.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5923825/

Initial Assessment and Stabilization

The initial assessment of a patient with hematemesis focuses on stabilizing the patient and determining the severity of bleeding. This involves:

1. Airway, Breathing, Circulation (ABC):
   • Ensure the patient has a patent airway, adequate breathing, and circulation. If necessary, intubation should be performed to protect the airway, particularly if the patient is obtunded or has ongoing massive bleeding.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7310600/
2. Vital Signs Monitoring:
   • Continuous monitoring of blood pressure, heart rate, oxygen saturation, and mental status is essential. Hypotension, tachycardia, and altered consciousness may indicate significant blood loss and shock.
3. Intravenous Access and Fluid Resuscitation:
   • Establish two large-bore intravenous lines for fluid resuscitation. Administer isotonic crystalloids (e.g., normal saline or lactated Ringer’s solution) to maintain hemodynamic stability.
4. Blood Transfusion:
   • In cases of severe anemia or ongoing massive bleeding, transfusion of packed red blood cells may be required to maintain hemoglobin levels and tissue oxygenation.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6286940/
5. Nasogastric Tube Placement:
   • While controversial, a nasogastric tube may be used to aspirate gastric contents, assess ongoing bleeding, and facilitate gastric lavage in some cases.

Detailed History and Physical Examination

1. History:
   • Obtain a detailed history focusing on the onset, duration, and frequency of hematemesis. Inquire about associated symptoms such as abdominal pain, melena, hematochezia, or changes in bowel habits.
   • Consider risk factors like NSAID or anticoagulant use, alcohol consumption, liver disease, recent vomiting episodes, and prior history of peptic ulcers or GI bleeding.
2. Physical Examination:
   • Conduct a thorough physical examination, emphasizing the abdominal and rectal examination.
   • Look for signs of chronic liver disease (e.g., jaundice, ascites, spider angiomas) that may suggest esophageal varices.
   • Check for epigastric tenderness, which may indicate peptic ulcer disease.
   • Perform a rectal examination to assess for melena, which could indicate upper GI bleeding.

Diagnostic Workup

1. Laboratory Tests:
   • Complete Blood Count (CBC): Assess hemoglobin, hematocrit, and platelet levels. A low hemoglobin level may indicate significant blood loss.
   • Coagulation Profile: Includes prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) to evaluate clotting status, particularly in patients with liver disease.
   • Liver Function Tests (LFTs): To assess for underlying liver disease, which may predispose to esophageal varices.
   • Blood Urea Nitrogen (BUN) and Creatinine: Elevated BUN may indicate upper GI bleeding due to the breakdown of blood proteins.
2. Imaging Studies:
   • Abdominal Ultrasound: Useful in detecting liver cirrhosis, ascites, or splenomegaly, which are suggestive of portal hypertension and esophageal varices.
   • CT Scan: May be indicated in cases where a mass or neoplasm is suspected, or if the source of bleeding is not apparent after initial evaluation.
   • Endoscopy: The gold standard for diagnosing and treating the cause of hematemesis. It allows direct visualization of the upper GI tract, identification of bleeding sources, and therapeutic intervention such as banding or sclerotherapy for varices, clipping, or injection for ulcers.

Management of Hematemesis

1. Peptic Ulcer Disease:
   • Proton Pump Inhibitors (PPIs): High-dose PPIs are the mainstay of treatment, reducing gastric acid production and promoting ulcer healing.
   • Endoscopic Therapy: Options include thermal coagulation, clipping, or injection with epinephrine. Surgery is reserved for cases where endoscopic treatment fails.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6611825/
2. Esophageal Varices:
   • Pharmacologic Therapy: Administer vasoactive drugs such as octreotide or terlipressin to reduce portal pressure and variceal bleeding.
   • Endoscopic Therapy: Band ligation or sclerotherapy is the primary treatment for active variceal bleeding.
   • Balloon Tamponade: A temporary measure to control massive bleeding until definitive therapy is possible.
   • Transjugular Intrahepatic Portosystemic Shunt (TIPS): Considered in refractory cases where bleeding cannot be controlled by endoscopy.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4313413/
3. Gastritis:
   • Antacids and PPIs: Used to reduce gastric acidity and promote mucosal healing.
   • H. pylori Eradication: If H. pylori infection is confirmed, appropriate antibiotic therapy is initiated.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6634133/
4. Mallory-Weiss Tear:
   • Supportive Care: Most cases resolve spontaneously with supportive care, including antiemetics and PPIs.
   • Endoscopic Therapy: Required if bleeding persists, involving thermal coagulation or clipping of the tear.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5921804/
5. Gastroesophageal Reflux Disease (GERD):
   • Lifestyle Modifications: Advise the patient to avoid foods and beverages that trigger reflux, maintain an upright posture after meals, and lose weight if necessary.
   • Pharmacologic Therapy: PPIs or H2 receptor antagonists are used to reduce acid production and manage erosive esophagitis.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7437074/
6. Neoplasms:
   • Oncologic Referral: Patients with suspected or confirmed GI neoplasms should be referred for oncologic evaluation and management, which may include surgery, chemotherapy, or radiation therapy.
7. Dieulafoy’s Lesion:
   • Endoscopic Therapy: The first-line treatment involves endoscopic coagulation, clipping, or banding to control bleeding.
   • Surgery: Rarely required, reserved for cases where endoscopic management is unsuccessful.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6622291/

Preventive Measures and Long-term Management

1. Prophylaxis for Esophageal Varices:
   • Nonselective Beta-Blockers: Used to reduce portal pressure and prevent variceal bleeding in patients with cirrhosis.
   • Endoscopic Surveillance: Regular endoscopy to monitor for variceal development and initiate preventive treatment.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697458/
2. H. pylori Eradication:
   • Triple Therapy: A combination of two antibiotics (e.g., clarithromycin and amoxicillin) and a PPI is effective in eradicating H. pylori and preventing ulcer recurrence.
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6782371/
3. Avoidance of NSAIDs and Alcohol:
   • Advise patients to avoid NSAIDs and alcohol, which can exacerbate or precipitate GI bleeding, particularly in those with a history of ulcers or gastritis.
4. Surveillance for GI Neoplasms:
   • Regular screening and surveillance endoscopy may be warranted for patients with risk factors for GI cancers, such as Barrett’s esophagus or a family history of gastric cancer.

Conclusion

The assessment and management of hematemesis are critical skills for medical students and healthcare professionals, requiring a systematic approach to ensure prompt diagnosis and appropriate treatment. By understanding the underlying causes, performing a thorough clinical evaluation, and utilizing evidence-based management strategies, clinicians can significantly improve patient outcomes. This guide serves as a comprehensive resource to aid in the effective assessment and management of hematemesis in clinical practice.