Hematemesis
Hematemesis is the vomiting of blood.[1] The source is generally the upper gastrointestinal tract, typically above the suspensory muscle of duodenum.[1] Patients can easily confuse it with hemoptysis (coughing up blood), although the latter is more common. Hematemesis "is always an important sign".[1]
| Hematemesis | |
|---|---|
| Other names | Haematemesis |
| Specialty | General surgery, gastroenterology |
Causes
Causes can be:
- Mallory-Weiss syndrome: bleeding tears in the esophagal mucosa, usually caused by prolonged and vigorous retching.
- Irritation or erosion of the lining of the esophagus or stomach
- Vomiting of ingested blood after hemorrhage in the oral cavity, nose or throat
- Vascular malfunctions of the gastrointestinal tract, such as bleeding gastric varices or intestinal varices
- Tumors of the stomach or esophagus.
- Radiation poisoning
- Viral hemorrhagic fevers
- Gastroenteritis
- Gastritis
- Peptic ulcer
- Chronic viral hepatitis
- Intestinal schistosomiasis (caused by the parasite Schistosoma mansoni)
- History of smoking
- Iatrogenic injury (invasive procedure such as endoscopy or transesophageal echocardiography)
- Zollinger–Ellison syndrome (severe peptic ulcer)
- Atrio-oesophageal fistula
- Yellow fever
Management
Hematemesis is treated as a medical emergency. The most vital distinction is whether there is blood loss sufficient to cause shock. Correct management is required in such conditions. It is required to perform all tests such as endoscopy before medication. A platelet test is also an important test in such conditions. Medicines such as painkillers or antibiotics eg. ciprofloxacin, could decrease platelet count which can lead to thrombocytopenia (when the body does not have sufficient platelets in the blood and cannot form clots). In such conditions wrong medication or management could be deadly. Blood transfusion is required in such conditions if the body loses more than 20 percent of body blood volume. Severe loss makes it impossible for the heart to pump a sufficient amount of blood to the body. In such conditions unmaintained blood volume could lead to Hypovolemic Shock (hypovolemic shock could lead to damage of body organs eg. kidney, brain, or gangrene of arms or legs). Note that an untreated patient could suffer cerebral atrophy.
Minimal blood loss
In cases that do not involve shock, the patient is generally administered a proton pump inhibitor (e.g. omeprazole), given blood transfusions (if the level of hemoglobin is extremely low, that is less than 8.0 g/dL or 4.5–5.0 mmol/L), and kept NPO, which stands for "nil per os" (Latin for "nothing by mouth", or no eating or drinking) until endoscopy can be arranged. Adequate venous access (large-bore cannulas or a central venous catheter) is generally obtained in case the patient suffers a further bleed and becomes unstable.
Significant blood loss
In a "hemodynamically significant" case of hematemesis, that is hypovolemic shock, resuscitation is an immediate priority to prevent cardiac arrest. Fluids and/or blood is administered, preferably by large bore intravenous cannula, and the patient is prepared for emergency endoscopy, which is typically done in theatres. Surgical opinion is usually sought in case the source of bleeding cannot be identified endoscopically, and laparotomy is necessary. Securing the airway is a top priority in hematemesis patients, especially those with a disturbed conscious level (hepatic encephalopathy in esophageal varices patient.) A cuffed endotracheal tube could be a life saving choice.
Techniques
Hematemesis, melena, and hematochezia are symptoms of acute gastrointestinal bleeding. Bleeding that brings the patient to the physician is a potential emergency and must be considered as such until its seriousness can be evaluated. The goals in managing a major acute gastrointestinal hemorrhage are to treat hypovolemia by restoring the blood volume to normal, to make a diagnosis of the bleeding site and its underlying cause, and to treat the cause of the bleeding as definitively as possible. The history should be directed toward (1) confirming the presence of bleeding; (2) estimating its amount and rapidity; (3) identifying the source and potential specific causes; and (4) eliciting the presence of serious associated diseases that might adversely affect the outcome. The information obtained is especially helpful in identifying situations that require aggressive management.
References
- Interpreting Signs and Symptoms. Nursing. Lippincott Williams & Wilkins. 2007. pp. 308–9. ISBN 9781582556680.
