Hematemesis is the vomiting of blood. We’ve all had the unpleasant experience of vomitting and, from time to time, may have vomited specks of blood. This usually doesn’t indicate anything serious. However, if fresh blood alone is vomited, this is known as hematemesis and is usually a symptom of internal bleeding from the upper digestive tract. The vomited blood may be bright red (fresh) or brownish-black (coagulated).
Hematemesis is a medical emergency that requires immediate treatment. This article explains how clinicians stop the bleeding as well as everything you need to know about hematemesis.
Causes of hematemesis
Most common causes of vomiting blood
The most common cause of vomiting blood is upper gastrointestinal tract bleeding caused by:1
- Bleeding ulcers: Peptic ulcers are open lesions in the stomach and duodenum (duodenal and gastric ulcers). They often bleed when left untreated
- Inflammation: Acute inflammation of the food pipe (oesophagitis), small intestine (duodenitis), and stomach lining (gastritis) caused by alcoholism, non-steroidal anti-inflammatory drug (NSAID) use, and reflux (GERD) results in arterial bleeding of the upper GI tract
- Variceal bleeding: Varices are enlarged blood vessels present in the food pipe and stomach. They are often caused by cirrhosis-induced portal hypertension- scar tissue in the liver (cirrhosis) which compresses blood vessel, reducing blood flow through the portal vein and causing blood to be redirected to other veins.2 The pressure-build up in varices can cause them to rupture resulting in heavy bleeds
- Chronic pancreatitis: It results in damage to pancreatic blood vessels, leading to a haemorrhage
Less common causes of vomiting blood
Less common causes of vomiting blood are:1
- Mallory Weiss tear: A tear in the oesophagus and stomach caused by increased blood pressure due to habitual alcohol intake, chronic vomiting, violent coughing, or hiccupping. It results in internal bleeding
- Cancer: Benign or malignant upper GI tract and pancreatic tumours can rupture and bleed
- Vascular abnormalities and injuries: Abnormal blood vessels and traumatic injuries to the gut can cause internal bleeding
- Radiation poisoning and uncommon GI tract infections are rare causes of vomiting blood. At times, swallowing blood from nose bleeds results in hematemesis
Signs and symptoms of hematemesis
Hematemesis is often a symptom of internal bleeding from the upper GI tract. Bleeding may originate from the oesophagus (food pipe), stomach, or duodenum (the first part of the small intestine).
Vomiting bright red blood points to heavy, active, or ongoing bleeding that requires urgent medical attention.
Bloody vomit that’s brown and lumpy (Coffee ground emesis) indicates a slower bleed or one that’s coagulated.
The other symptoms of upper GI bleeding that accompany hematemesis are:1
- Melena (Black, tarry stools)
- Abdominal pain
Management and treatment for hematemesis
The primary focus of the management of hematemesis is to stop the bleeding and treat the underlying cause.4 If a chronic condition is the cause of bleeding, it may be harder to treat.
The treatment of hematemesis includes:
Severe blood loss requires immediate fluid/blood replacement. IV fluids help stabilise patients (especially those with co-morbidities). A blood transfusion is needed for active bleeds and if haemoglobin levels fall below 10 g/dL. Oxygen is also given via a face mask or nasal prongs
- Physical exam and medication
Patients with chronic conditions are given cardiorespiratory support and disease-specific medicines. Protein pump inhibitors (PPIs), vasoactive drugs, and clot-promoting agents manage minor bleeding and prevent re-bleeding in high-risk patients
- Endoscopic therapy
Treats re-bleeds and actively bleeding oesophageal varices, peptic ulcers, and vascular abnormalities. Instruments like clips and cautery devices attached to an endoscope stop the bleeding once the source is located
Required for severe ongoing bleeding and re-bleeding after endoscopic and drugs fails. It’s needed in patients with bleeding peptic ulcers and gastrointestinal cancers
Diagnosis of hematemesis
Healthcare providers perform tests to determine the underlying cause and source of bleeding. They include:
- Clinical assessment: Clinicians determine the nature of bleeding by checking the patient’s pulse and blood pressure and asking questions regarding the patient’s symptoms and medical history
- Blood tests: Used to determine the level of blood loss, whether IV fluids or blood transfusion is needed, and to assess liver function
- Imaging tests: Help in finding the cause and source of bleeding. These tests may include – X-ray, CT scan, MRI, upper endoscopy, gastroscopy, or ultrasound
The risk factors of hematemesis include:1
- Old age
- Gastrointestinal disorders, liver disease, and pancreatic conditions.
- Chronic vomiting
- Medications like NSAIDs, aspirin, and anticoagulants
- Gastrointestinal surgery
- Traumatic injuries to the upper gastrointestinal tract.
Vomiting blood is a medical emergency. If not treated promptly, it could result in the following complications:
- Aspiration/ Choking
A rare complication resulting in blood pooling in the lungs, causing difficulty in breathing. People at risk of aspirating bloody vomit are older adults and those with a history of strokes, alcoholism, and swallowing disabilities
Excessive bleeding causes anaemia, a deficiency of red blood cells. Anaemia is obvious when bleeding is fast and sudden butut it can also be asymptomatic and develop after a long time
Severe blood loss means the heart can’t get the oxygen it needs to function and can lead to organ failure and death
How common is hematemesis
As hematemesis is a sympton of an underlying condition, it is difficult to say how common it is. The most common cause of hematemesis is upper GI bleeding which accounts for 70,000 hospital admissions in the UK each year. It’s twice as common in men than in women, is more prevalent as people age (>60 years), and has a high mortality (13%).
How can I prevent hematemesis
If hematemesis is caused byupper gastrointestinal bleeding, preventative measures can include:
- Limiting NSAIDs and aspirin use (Only take when necessary)
- Avoiding drinking alcohol
- Avoiding or stopping smoking tobacco
- Getting treated for gastrointestinal disorders.
- Getting tested for H. pylori, especially if at risk of developing ulcers
- Lowering stress levels by practising various relaxation methods
- Maintaining a healthy weight and active lifestyle by eating a balanced diet and regularly exercising
When should I see a doctor
Always contact your doctor if you’re vomiting blood. Seek emergency medical attention if you’re experiencing additional symptoms like:
- Rapid or shallow breathing
- Cold, clammy, and pale skin
- Severe chest and abdominal pain
- Disorientation/ Confusion
- Light-headedness/ Faintness
- Blurry vision
- Low urine output
Hematemesis is vomiting blood. It’s often a symptom of upper GI bleeding caused by bleeding ulcers, inflammation, ruptured enlarged veins (varices), tumours, etc. Hematemesis requires emergency medical attention. Untreated hematemesis results in severe blood loss, leading to shock and possible death. Fortunately, timely treatment prevents worst-case scenarios.
- Prakhar Nagar, P Vardaraju, K Kuberan, Prevalence of Causative Factors Involved in Hematemesis, J Res Med Dent Sci [Internet]. 2021 [cited 2023 May 18]; 9 (5):124-131. Available from: https://www.jrmds.in/articles/prevalence-of-causative-factors-involved-in-hematemesis-77113.html#ai
- Iwakiri Y. Pathophysiology of portal hypertension. Clinics in liver disease [Internet]. 2014 May [cited 2023 Jun 16];18(2):281. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3971388/
- Wilson ID. Hematemesis, melena, and hematochezia. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations [Internet]. 3rd ed. Boston: Butterworths; 1990 [cited 2023 Jun 16]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK411/
- Palmer K. Management of haematemesis and melaena. Postgraduate medical journal [Internet]. 2004 Jul 1 [cited 2023 May 18];80(945):399-404. Available from: https://pmj.bmj.com/content/postgradmedj/80/945/399.full.pdf