Generality
Hematemesis consists of the emission of blood with vomiting . This manifestation generally indicates an ongoing or recent blood loss from the upper part of the gastrointestinal tract (esophagus, stomach or duodenum).
Hematemesis can result from various pathologies, including: oesophageal diverticula, gastric or duodenal ulcer, liver cirrhosis, esophagitis, gastritis, esophagus or stomach cancer and esophageal varices.
Hematemesis is always a serious clinical sign ; as such, it must be evaluated by a doctor under an emergency regime.
To treat hematemesis it is necessary to identify the cause. Depending on the severity, the doctor may indicate a pharmacological treatment (eg administration of hemostatic drugs) or, in the most severe cases, a series of blood transfusions or surgery.
What's this
What is meant by Ematemesi?
Hematemesis indicates a blood loss from the stomach, esophagus or duodenum through vomiting (also called emesis ).
The expelled blood appears bright red ; this indicates that:
- The blood loss is ongoing or recent (the blood has not yet undergone the digestive action of the gastric juices, therefore it does not turn to brown-black);
- Bleeding is prolonged over time or of such magnitude that it immediately stimulates vomiting due to the stretching of the gastric walls.
Meaning of the term
Hematemesis is a term deriving from the Greek " àima ", which means " blood " and " èmesis ", that is " vomit ".
Causes
Different diseases of the digestive system can be complicated by blood loss or real bleeding. Hematemesis indicates an ongoing or recent bleeding that comes from the first part of the gastrointestinal tract ( esophagus, stomach or duodenum ).
To learn more: Gastrointestinal Hemorrhages - What they are, Symptoms and Causes »In hematemesis, the blood is fresh, so it appears bright red in color .
If the material expelled with the emesis is brownish-black (similar to the color of the coffee), sometimes granular, one speaks, more properly, of vomiting from the ocean, a sign of a hemorrhage of the upper gastrointestinal tract that has ended or is being reduced anyway . This last case indicates that the blood has undergone the digestive action of the gastric juices: the hemoglobin present in the stomach is degraded to hematin by hydrochloric acid and the vomitus assumes a darker color.
Vomiting with Blood: where does it originate?
The origin of hematemesis is the upper gastrointestinal tract, typically above the Treitz ligament (or suspensory ligament of the duodenum, ie the structure that fixes the last stretch of the duodenum to the right portion of the esophageal hiatus).
As anticipated, when the bleeding concerns the highest portion of the digestive canal and results in an entity such as to be expelled with emesis before being able to be oxidized by the acid pH of the stomach, hematemesis results in a bright red color.
Hematemesis: what are the main causes of Vomiting with Blood?
The most frequent causes of hematemesis are:
- Gastroduodenal ulcer ;
- Rupture of the esophageal varices (dilation of the veins of the esophagus) in the context of liver diseases, in particular of liver cirrhosis .
In the latter case, the hematemesis derives from the increase in blood pressure in the portal circulation, secondary to the subversion of the architecture of the liver. The peptic ulcer (gastric or duodenal) produces, instead, vomiting of blood due to the erosion of blood vessels of a certain caliber.
Hematemesis can also be found in the presence of:
- Acute and severe gastritis;
- Esophagitis;
- Tumors of the stomach, duodenum or esophagus;
- Vascular malformations of the gastrointestinal tract;
- Inflammatory bowel diseases;
- Intestinal infarction.
The following can also contribute to the emergence of hematemesis:
- Trauma (mostly abdominal);
- Chronic alcohol abuse;
- Taking certain medications (eg treatment with NSAIDs, anticoagulants, etc.);
- Instrumental diagnostic investigations (iatrogenic lesions secondary to invasive procedures such as, for example, transesophageal echocardiography);
- Complications of endoscopic interventions.
The risk of developing severe digestive bleeding, with the appearance of hematemesis, is also present in people suffering from:
- Esophageal diverticula;
- Coagulation disorders;
- Chronic liver disease (on an alcohol or viral basis).
Other causes of hematemesis are:
- Gastroenteritis;
- Viral hemorrhagic fever (including ebola, Marburg fever, f. Of Lassa and Rift Valley, hantavirus infections, yellow fever and dengue fever);
- Mallory-Weiss syndrome;
- Intestinal schistosomiasis;
- Zollinger-Ellison syndrome;
- Exposure to radiation.
Hematemesis can also be determined by the inflammation of the gastrointestinal lining due to the ingestion of foreign bodies or caustic substances. Finally, vomiting of ingested blood is possible after bleeding into the oral cavity, nose or throat.
Symptoms and Complications
Did you know that…
A gastrointestinal haemorrhage can result from any point of the digestive tract, from the mouth to the anus. Compared to the onset modes, bleeding can be acute or chronic, obvious or occult .
Hematemesis: how does it manifest itself?
Hematemesis occurs with the vomiting that is characterized by the emission of bright red blood . This aspect makes it possible to distinguish the condition from coffee vomiting, in which the blood remains for some time in the stomach, where it is partially digested by gastric juices. In the latter case, therefore, the blood appears brownish-black in color, due to the action of the gastric acids, the hemoglobin is converted into hematin. In practice, hematemesis occurs when bleeding is still ongoing, while coffee vomiting is indicative of bleeding from the upper gastrointestinal tract that is being reduced or has already stopped.
In hematemesis, the extent of bleeding and associated manifestations depend on the site and the underlying concomitant disease.
Acute gastrointestinal bleeding that occurs with sudden and severe haematemesis can potentially lead to patient death within a few hours. Less frequently, on the other hand, hematemesis is associated with chronic bleedings that develop gradually over time and lead to a small blood loss.
In the vomited material, the blood can present itself in a fluid form or in agglomerates (clots). In some cases, hematemesis may contain food residues .
Note
Patients can easily confuse hematemesis with hemoptysis (cough with blood), although the latter is more common.
What other symptoms occur?
The symptomatology correlated to the emergence of hematemesis is variable and results strictly dependent on the severity of the bleeding.
For example, if blood loss is limited, the patient may be completely asymptomatic; when bleeding is significant, on the other hand, it can cause hypotension and tachycardia due to volume loss.
Hematemesis is preceded by some symptoms, such as:
- Taste of blood in the mouth ;
- Abdominal pain : if hematemesis has a gastric cause, there is violent pain and / or sensation of heat at epigastric level.
Hematemesis can be associated with late signs, related to bleeding from the upper gastrointestinal tract, such as:
- Enterorrhagia : emission of bright red blood from the rectum;
- Melena : evacuation of picee stools, that is dark color, tarry and smelly appearance; when it is associated with hematemesis, the melena indicates a bleeding that lasts even for several hours, taking into account that the average time of intestinal transit is 72 hours;
Hematemesis can also lead to other clinical manifestations that depend on the progressive decrease in the volume of circulating blood (hypovolaemia), including:
- Asthenia;
- Anemia (acute or progressive; it may be such as to require hospitalization);
- Sense of lightheadedness or mental confusion;
- Tachycardia;
- Lowering of pressure (arterial hypotension);
- tachypnea;
- Skin pallor;
- Intense sweating.
Diagnosis
Hematemesis: when to go to the doctor?
Hematemesis derives from acute gastrointestinal bleeding and, as such, must be considered a potential emergency . Therefore, in the case of vomiting with blood, it is always advisable to contact your primary care physician as soon as possible or go to the nearest emergency room .
Patient assessment should be directed to:
- Confirm the presence of bleeding;
- Estimate the amount and speed of bleeding;
- Identify the source of blood loss and potential specific causes;
- Consider the concomitant presence of serious diseases or contributing factors, which could negatively affect the management of hematemesis.
Hematemesis: which exams are indicated?
- As soon as the patient's clinical conditions allow it, an endoscopic examination ( gastric fibroscopy or esophagogastroduodenoscopy ) is performed; this allows you to view the bleeding site and plan a correct therapeutic strategy . When the patient is unstable or the situation is rapidly evolving, an emergency endoscopy is performed.
- The emission of small quantities of chronic and concealed blood can only be detected by laboratory tests on a stool sample ( occult blood search in faeces ). Blood tests instead show a progressive or acute anemization. In addition to CBC, the determination of prothrombin time (PT), partial thromboplastin time (PTT), electrolytes and creatininemia may be indicated.
- Other investigations that may be indicated in case of suspected massive blood loss are blood gas analysis and electrocardiogram (to highlight alterations in heart rhythm and possible fatigue of the heart pump).
Treatment
The treatment of digestive hemorrhage must be timely and, in general, it is always necessary to stop the bleeding .
The management of hematemesis can include: rest, ice bag on the abdomen, administration of hemostatic drugs, abstention from the introduction of food and, in the most serious cases, transfusions or surgical approaches. Endoscopy allows you to plan where to intervene or, if possible, temporarily stop the hemorrhage from which the hematemesis originates.
First aid: objectives
Hematemesis is a symptom of acute gastrointestinal hemorrhage, therefore, until the severity of the condition can be appropriately assessed with targeted diagnostic investigations, the patient needs medical interventions and supportive measures useful to avoid clinical instability.
Secondly, the management of hematemesis has the following objectives:
- Treat hypovolemia, restoring normal blood volume (note: blood transfusion is necessary if the body loses more than 20% of the body's blood volume);
- Make a diagnosis of the site from which the bleeding originates and its underlying cause;
- Intervene on the cause of bleeding in the most definitive way possible.
Always under emergency conditions, the doctor assesses whether the loss of blood can be sufficient to cause hypovolemic shock . In this case, the incorrect management of the emesis could lead to the death of the patient. For example, the administration of some drugs, such as painkillers or antibiotics, can cause thrombocytopenia, aggravating the clinical picture.
The treatment of massive hemorrhages at the origin of hematemesis is commonly surgical or endoscopic.
Hematemesis: which treatment is expected?
In 80% of patients with hematemesis, the course is benign and the bleeding undergoes spontaneous self-limitation. In the remaining percentage of cases, however, the bleeding appears severe.
If hematemesis is associated with mild blood loss, therapy may be conservative; generally, a proton pump inhibitor is administered and, when the hemoglobin level is extremely low, blood transfusions are performed.
Until the endoscopic examination can be performed, the patient must not drink or introduce food.
If the blood loss that occurs with hematemesis is significant, then a hypovolemic shock is established, the resuscitation of the patient is the immediate priority to prevent cardiac arrest. Through an intravenous catheter, blood products and fluids are administered, able to restore volume loss, and at the same time improve the patient's symptoms.
Esophageal varices can be treated endoscopically through cauterization and ligation; other pathologies make surgical techniques necessary that allow safe maneuvers to be performed on the organs from which the bleeding originates.
