1. Introduction: The Clinical Urgency of Haematemesis
Hematemesis is strictly defined as the vomiting of frank blood or "coffee ground" material (blood altered by gastric acid and digestive enzymes) originating from lesions proximal to the duodenojejunal junction. For the practicing physician, this presentation constitutes a potential medical emergency.
Immediate clinical priorities include rapid hemodynamic assessment and stabilization, followed by a systematic diagnostic approach to identify the underlying source and mitigate the risk of catastrophic hemorrhage.
2. Etiological Framework: Anatomical and Systemic Causes
Upper Gastrointestinal Sources
- Esophageal: Reflux esophagitis (typically minor bleeding), esophageal varices (often torrential), and esophageal carcinoma (usually presents as anemia or coffee grounds; large bleeds are unusual).
- Gastric: Peptic ulceration, acute gastric erosions, Mallory–Weiss syndrome, gastric carcinoma, leiomyoma/GIST (typically moderate bleeding with no preceding history), hereditary hemorrhagic telangiectasia (HHT), and vascular malformations (often presenting with no preceding history).
- Duodenal: Peptic ulceration (often acute with little background history), duodenal diverticula, aortoduodenal fistulae (typically massive hematemesis and melena following aneurysm repair), invasive pancreatic tumors, and hemobilia.
Non-GI and Swallowed Blood
- Epistaxis: Swallowed blood from a posterior nasal source.
- Hemoptysis: Blood originating from the respiratory tract that is subsequently swallowed and vomited.
Systemic and Pharmacological Factors
- Bleeding Disorders: Liver disease-associated coagulopathy, thrombocytopenia, and hemophilia.
- Pharmacological Agents: NSAIDs, aspirin, anticoagulants, and steroids.
- Other Conditions: Uremia and connective tissue disorders (e.g., polyarteritis nodosa).
3. Targeted Clinical History: Identifying the Source
A meticulous history serves as the primary tool for narrowing the differential diagnosis before invasive intervention.
- Esophageal Clues: Ask about excess alcohol consumption or known liver disease, which increases the suspicion of varices. Conversely, retrosternal burning and heartburn suggest esophagitis, while dysphagia may indicate carcinoma.
- The Mallory–Weiss Sequence: Characteristically seen in younger patients following a large meal and alcohol consumption. A forceful vomit of food is followed by a second vomit containing blood (Mallory-Weiss syndrome).
- Gastric Associations: Epigastric pain suggests peptic ulceration. Acute gastric erosions are frequently secondary to severe physiological stress: major surgery, pancreatitis, burns (Curling’s ulcer), or head injuries (Cushing’s ulcer). Note that GISTs and vascular malformations typically lack a preceding symptomatic history.
- Duodenal Presentations: In duodenal lesions, melena often predominates over hematemesis. Clinicians must be alert for acute presentations in patients with little to no background history of ulceration. Massive bleeding in a patient with a history of aortic graft surgery mandates immediate suspicion of an aortoduodenal fistula.
- Drug History: Mandate a specific inquiry into aspirin or NSAID use. Patients often overlook over-the-counter (OTC) proprietary preparations; these must be explicitly queried, as they are frequent drivers of erosive disease.
4. Physical Examination: From Hemodynamics to Systemic Markers
Hemodynamic Assessment
Initial examination must prioritize signs of shock. Tachycardia and hypotension, accompanied by peripheral vasoconstriction (cold, clammy skin), indicate significant volume loss.
Site-Specific Signs
- Portal Hypertension/Liver Disease: Assess for jaundice, ascites, abdominal distension, palmar erythema (liver palms), spider nevi, clubbing, gynecomastia, testicular atrophy, caput medusae, and hepatosplenomegaly.
- Oncological Markers: Palpate for an epigastric mass or a palpable left supraclavicular node (Virchow’s node) suggestive of gastric carcinoma. A palpable mass in the pancreatic region may indicate invasive malignancy.
Systemic and Rare Indicators
- Uremia: Look for pallor, a bronze skin tint, pulmonary/peripheral edema, pericarditis, hypertension, and retinopathy.
- Hereditary Hemorrhagic Telangiectasia: Visible telangiectasia on the lips and oral mucous membranes.
- Connective Tissue Disease: Polyarteritis nodosa may manifest with neuropathies, cardiac disease, or specific skin lesions.
5. Diagnostic Investigation Protocol
1. Laboratory Panel
- FBC and ESR: To identify anemia from chronic bleeding (common in carcinoma) and elevated ESR in connective tissue diseases.
- U&Es: Urea may be elevated due to the absorption of blood from the bowel or underlying renal failure (uremia).
- LFTs: Essential for identifying liver failure. Elevation in the context of biliary symptoms may suggest the rare diagnosis of hemobilia.
- Clotting Screen: Indicated for patients with liver disease, suspected diatheses, or those on anticoagulants.
2. The Gold Standard: OGD
Oesophago-gastro-duodenoscopy (OGD) is the definitive diagnostic modality. It allows for direct visualization of varices, ulcers, erosions, Mallory–Weiss syndrome tears, and carcinomas, while facilitating therapeutic intervention and biopsy.
3. Specialized Imaging
- Angiography: Indicated for identifying vascular malformations or distal duodenal sources.
- Ultrasound (US): Utilized to screen for aortic aneurysm.
- CT Scan: Specifically indicated if an aortic graft infection/fistula is suspected.
- Chest X-ray (CXR): Employed to rule out pulmonary lesions as a source of hemoptysis (swallowed blood differential).
6. Clinical Pearls for the Frontline Physician
- Prioritize Access: Mandate large-bore IV access (minimum 2 lines) and immediate cross-matching upon presentation.
- The Silent Tachycardia: In younger patients with high physiological reserve, tachycardia may be the only early sign of life-threatening GI hemorrhage.
- Massive Hemorrhage: Always consider varices or aortoduodenal fistulae in cases of torrential bleeding; conversely, esophagitis and carcinoma typically present with minor or chronic blood loss.
- Medication Vigilance: Perform a meticulous review of all OTC drug use, specifically aspirin and NSAIDs, which patients frequently fail to report as "medication."
7. Conclusion: The Bottom Line on Patient Care
The management of hematemesis demands a disciplined, systematic approach. By correlating the volume and nature of bleeding with targeted historical clues—such as the "food-then-blood" sequence of Mallory–Weiss syndrome or the acute onset of duodenal lesions—clinicians can effectively triage for definitive OGD.
Immediate stabilization and a high index of suspicion for drug-induced or systemic etiologies remain the cornerstones of reducing mortality in these patients.