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Vomiting Blood (Haematemesis)

Comprehending haematemesis

Haematemesis is the medical word for vomiting blood. This symptom is usually due to a problem within the upper gut. That is, the gullet (oesophagus), stomach or the first part of the small intestine (duodenum). There can be various causes for the same as listed below:

Haematemesis: a medical crisis. In many cases the bleeding will stop quite quickly but in some cases it can become severe and life-threatening.

So, what is the upper gut?

Gut (gastrointestinal tract) is the tube that starts at our mouth, and ends at our bottom (anus). The upper gut includes the gullet (oesophagus), stomach and first part of the small intestine or duodenum. Food passes down the oesophagus into the stomach. The stomach makes acid which is not essential but helps to digest food. After being mixed in the stomach, food passes into the duodenum, to be digested.

Forms of trickles from the upper gut

The type of bleeding is sometimes described as follows:

Dark blood. This is often referred to as a ‘coffee ground’ colour. This suggests that the bleed has been relatively slow. The blood has been in contact with stomach acid long enough for the acid to turn the blood a dark brown/red colour. The bleeding in this situation may not yet have been heavy. However, it may become heavy at a later time.

Voluminous bright red blood suggests a rapid and large bleed.

Melaena is the medical word for old, dark blood in stool or faeces. If one has Malena one’s stools become every dark or black. There is often a tar-like consistency. Vomiting blood and having melaena are symptoms that often go together. Having both symptoms together means that one has had a lot of bleeding into the gut.

Other symptoms may occur at the same time as vomiting blood. For example, tummy (abdominal) pain, high temperature (fever), feeling unwell, or other gut symptoms. If one loses a lot of blood, it can make one feel dizzy or even pass out. The presence and type of other symptoms may help to point to a cause of the bleeding. Sometimes there are no other symptoms at first.

Elements triggering vomiting blood

There are many possible factors. Below is a brief overview of the more common and important causes:

Blood oozing from the gullet oesophagus

Oesophageal varices. Varices are enlarged, swollen blood vessels in the lining of the gullet or stomach. They are one of possible complications of liver cirrhosis. In cirrhosis, scarred liver tissue blocks blood flow through the liver. This causes an increase in pressure in the vein that takes blood from the gut to the liver (the portal vein). The increased pressure pushes back into the gut and causes the veins to swell in the gullet. The swellings are quite fragile and may bleed heavily into the gullet.

Inflammation of Oesophagus (Oesophagitis) is often due to reflux of acid from the stomach (gastro-oesophageal disease (GORD) ) & can bleed.

Oesophageal cancer sometimes causes bleeding into the oesophagus.

Mallory-Weiss Syndrome is bleeding caused by a tear in the lining of oesopphagus or stomach. Anything that leads to a sudden rise in pressure in the stomach or the oesophagus can cause the tear. For example, repeated retching or vomiting, excessive straining, violent coughing or hiccupping.

Blood oozing from the stomach

Anti – inflmmatory medicines that are used to treat conditions such as arthritis, some times cause stomach ulcers. Aspirin, used commonly prevent blood clots can not only cause bleeding, it can make bleeding worse by stopping blood from clotting.

Mallory-Weiss syndrome may affect the lining of the stomach.

Stomach (Gastric) Ulcer: An ulcer is a small hole in the lining of the stomach. An ulcer may bleed, sometimes heavily. There are several causes of stomach ulcers, including:

Infection with a germ (Bactreia) called Helicobacter Pylori. This can usually be treated quite easily.

Stress.

Stomach cancer sometimes causes bleeding into stomach.

Inflammation of stomach lining (gastritis) has similar causes to stomach ulcers.

Varices in the lining of the stomach may occur similar to oesophageal varices described above.

Blood oozing from the duodenum

Duodenal Ulcer: An ulcer may bleed, sometimes heavily. Like stomach ulcers, a duodenal ulcer is usually caused by an infection with the germ (bacterium) called H. pylori. This can usually be treated quite easily. Anti-inflammatory medicines and aspirin, which are common causes of stomach ulcers, are uncommon causes of duodenal ulcers.

Inflammation of the duodenum lining (duodenitis) has similar causes to duodenal ulcers.

Rare causes from any part of the upper gut include:

Injury

Uncommon infections of the gut.

Radiation

poisoning.

No cause identified. Even after tests, in some cases the cause cannot be found

Bleeding which has not come from the gut

Sometimes when blood is vomited, it has not come from the gut. For example, if you have had a nose bleed and then swallowed the blood, you may vomit blood. Also sometimes it can be difficult to tell whether the blood has been vomited up from the gut, or coughed up.

Investigations needed

A doctor’s assessment

The doctor will try to find out if this blood is truly coming from the upper gut. Sometimes it is difficult to be sure. Sometimes it can be difficult to say if the blood is:

Haemoptysis – that is coughing of blood not vomiting.

Coming from somewhere in one’s mouth or nose that tracks to the back of your throat, which one then swallows and vomits back up. For example, from a nosebleed.

The doctor will also try to make a judgement about how much blood one has lost and how serious this is. They will be able to infer from what they are told and also by checking one’s pulse and blood pressure.

If it is clear that the blood is coming from the upper gut, tests are usually done to identify the cause.

Investigations

Blood test: Done to asses amount of blood remaining in ones body and to decide wheter there is need for transfusion. They will also help to identify other causes. Ex: Liver function tests for cirrhosis.

Gastroscopy: Almost all patients will need it to idetify the cause of the bleed and intial treatment to control the bleeding.

Therapeutics for vomiting blood

Inceptive therapy

The initial treatment may require a drip into a vein to supply fluid or even blood transfusion if the bleeding is severe. This may not be necessary if the bleeding has been minor and has stopped. However, if the bleeding is severe, full resuscitation and emergency fluid/blood replacement may be required.

Alternative therapeutics

This will depend on the cause. However, an initial treatment to stop any ongoing bleeding can often be done by using instruments that can be passed down the endoscope. Occasionally, emergency surgery is needed to control severe ongoing bleeding. Once bleeding is stopped, further treatment depends on the cause.​