Hematemesis is the vomiting of blood and typically indicates upper gastrointestinal (GI) bleeding originating proximal to the ligament of Treitz, which suspends the duodenum at its junction with the jejunum. The appearance of vomitus provides initial diagnostic clues: bright red or streaked blood suggests recent or active bleeding, while dark red, brown, or “coffee-ground” vomitus indicates partially digested blood retained in the stomach.

Hematemesis is a potentially serious clinical sign and may result from a spectrum of conditions, including peptic ulcer disease, esophageal varices, gastritis, Mallory-Weiss tears, esophageal rupture, malignancies, or coagulopathies. In certain cases, swallowed blood from epistaxis or oropharyngeal lesions can mimic true hematemesis. Risk factors include NSAID or anticoagulant use, alcohol consumption, trauma, and systemic diseases affecting coagulation. Early recognition, prompt evaluation, and stabilization are crucial to prevent morbidity and mortality.

Pathophysiology

1. Mucosal Injury: Gastric or esophageal mucosal erosion allows blood to enter the lumen, e.g., in gastritis or ulcers.

2. Vascular Lesions: Rupture of vessels, as seen in esophageal varices or arterial ulcers, causes massive bleeding.

3. Coagulopathy: Impaired hemostasis (e.g., thrombocytopenia, hemophilia, anticoagulation therapy) exacerbates mucosal bleeding.

4. Mechanical Trauma: Forceful vomiting, instrumentation, or foreign bodies can tear the mucosa (Mallory-Weiss, esophageal rupture).

Types of Hematemesis

History and Physical Examination

History

• Onset, duration, and quantity of hematemesis

• Color, consistency (bright red vs coffee-ground)

• Associated symptoms: melena, hematochezia, nausea, retching

• Risk factors: NSAIDs, alcohol, anticoagulants, trauma, liver disease

• Past GI disorders: ulcers, varices, gastritis, cancer

Physical Examination

• Vital signs: monitor for orthostatic hypotension (systolic drop ≥10 mmHg or pulse increase ≥10 bpm)

• Skin and mucosa: pallor, cyanosis, signs of coagulopathy

• Abdominal exam: tenderness, masses, organomegaly

• Signs of shock: tachycardia, hypotension, diaphoresis

• Special exams: inspect nasopharynx to exclude swallowed blood

Diagnostic Approach

• Laboratory: CBC, coagulation profile, blood typing, renal and liver function

• Nasogastric Tube Aspirate: Assess for ongoing bleeding

• Endoscopy (EGD): Identify source and allow therapeutic intervention

• Imaging: Only if perforation or mass suspected (CT, angiography)

Causes of Hematemesis

Gastrointestinal Causes

Non-Gastrointestinal / Systemic Causes

Emergency Interventions

• Place patient supine, elevate feet 20–30° if hypotensive

• Establish large-bore IV access; fluid resuscitation

• Monitor vital signs, urine output, and mental status

• Oxygen administration as indicated

• Nasogastric lavage for assessment and aspiration

• Urgent endoscopy for diagnosis and hemostasis

• Sengstaken-Blakemore tube for variceal bleeding

Patient Counseling

• Avoid NSAIDs, alcohol, and irritant foods

• Adhere to prescribed medications (e.g., PPIs, vasoactive drugs)

• Maintain hydration and report recurrent bleeding promptly

Pediatric Considerations

• Hematemesis is rare; consider foreign body, swallowed maternal blood, hemorrhagic disease, or esophageal erosion

• Prompt fluid replacement and specialist referral are critical

Geriatric Considerations

• Increased risk due to ulcers, vascular anomalies, malignancy, or chronic NSAID use

• Coexisting liver, renal, or pulmonary disease may worsen outcomes

References

1. Al-Ebrahim, F., Khan, K. J., Alhazzani, W., Alnemer, A., Alzahrani, A., Marshall, J., & Armstrong, D. (2012). Safety of esophagogastroduodenoscopy within 30 days of myocardial infarction: A retrospective cohort study from a Canadian tertiary centre. Canadian Journal of Gastroenterology, 26, 151–154.

2. Cappell, M. S. (2009). Problems with combining EGD, PEG, flexible sigmoidoscopy, and colonoscopy to analyze risks of endoscopic procedures after MI: A call for stratifying risk according to individual procedures. Journal of Clinical Gastroenterology, 43, 98–99.

3. Laine, L., & Jensen, D. M. (2012). Management of patients with ulcer bleeding. American Journal of Gastroenterology, 107(3), 345–360.

4. Sarin, S. K., & Kumar, A. (2002). Diagnosis and management of variceal hemorrhage. New England Journal of Medicine, 347, 813–822.

5. Bank, S., & Cheng, A. (2011). Upper gastrointestinal bleeding: Clinical features, evaluation, and management. Gastroenterology Clinics of North America, 40(4), 655–678.