Hematemesis

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Overview
Hematemesis or haematemesis is the vomiting of blood. The source is generally the upper gastrointestinal tract (UGI). Patients can easily confuse it with hemoptysis (coughing up blood), although the former is more common. The most common causes of upper GI bleeding include bleeding peptic ulcer disease, gastritis, and variceal bleed. A nasogastric tube lavage that yields blood or coffee-ground like material confirms the diagnosis and predicts whether bleeding is caused by a high-risk lesion. The initial evaluation of the patient with UGI bleeding involves an assessment of hemodynamic stability and resuscitation if necessary. Upper endoscopy usually follows, with the goal of both diagnosis, and in some circumstances, treatment of the specific disorder. Important elements of the history include use of NSAIDs, alcohol, history of liver disease or variceal bleeding, history of ulcers, weight loss, dysphagia, or an abdominal aortic aneurysm (AAA). The latter may indicate aortoenteric fistula. Any recent surgical procedure especially one involving the GI tract is also relevant. Endoscopic, clinical, and laboratory features are useful for risk stratification of patients who present with UGI bleeding. In addition, gastroenterology and surgical consultation are usually required, especially for high risk patients.

Significant Associated Signs and Symptoms
Associated symptoms and signs of hematemesis may include:
 * Signs of liver disease (ascites, hepatomegaly, telangiectasia, etc)
 * Any esopho-gastric symptoms, such as nausea, vomiting, and epigastic tenderness may indicate peptic ulcer disease.
 * Dark colored, tar like stools (a condition known as melena). This usually supports upper GI bleed as opposed to lower GI bleed.
 * Symptoms of weight loss, early satiety, or loss of appetite raise suspicions for malignant process such as gastric adenocarcinoma.
 * Any significant psychiatric history or symptoms of severe depression or psychosis may indicate iatrogenic upper GI bleed related to pill esophagitis, foreign body ingestion, or munchausen syndrome by proxy (a reason for recurrent haemtemesis in children).
 * Vesicular rash of the lips or the oral cavity may indicate esophagitis related to herpes simplex virus infection.
 * Oral thrush in combination with dysphagia and/or odynophagia usually indicate candida esophagitis.
 * Associated bleeding in other organs ( skin, mucosal bleed, GU, joints, etc) indicates coagulopathy ( ITP, hemophila, heparin, von willebrand disease, etc).
 * Signs of associated congential or inherited disease such as mucosal telangiectasias in hereditary hemorrhagic telangiectasia, intestinal duplication, congenital cysts, etc..
 * Facial flushing, intermittent diarrhea, and abdominal pain indicate carcinoid syndrome, a rare cause of upper GI bleed.
 * Severe and diffuse upper GI ulcerations with chronic diarrhea usually indicate Zollinger Ellison syndrome or gastrenoma.

Complete Differential Diagnosis of the Causes of Hematemesis
(In alphabetical order)


 * Abciximab
 * Acute esophageal necrosis (AEN)
 * Adenocarcinoma
 * Alendronate induced esophagitis
 * Angiodysplasia
 * Angioma
 * Aortic Coarctation
 * Aortoenteric fistula
 * Arterial, venous, or other vascular malformations
 * Aspirin induced ulcers or gastritis
 * Blue rubber bleb nevus syndrome
 * Candida albicans esophagitis
 * Carcinoid tumors in the stomach
 * Caustic ingestion
 * Clopidogrel
 * Coagulopathy
 * Congenital malformations
 * Coumadin
 * Cow's milk allergy is a significant reason for haematemesis in newborns
 * Crimean-Congo hemorrhagic fever
 * Cytomegalovirus esophagitis
 * Dieulafoy's lesion
 * Disseminated intravascular coagulation
 * Drotrecogin alfa
 * Drug-induced thrombocytopenia
 * Duodenal varices
 * Duplication cysts
 * Ehlers-Danlos syndrome
 * Esophageal cancer
 * Esophageal dilatation (iatrogenic)
 * Esophageal melanosis
 * Esophagitis
 * Foreign body ingestion especially in children
 * Gastric varices
 * Helicobacter pylorirelated gastritis or peptic ulcer disease
 * Hemobilia
 * Hemophilia
 * Hemosuccus pancreaticus
 * Heparin
 * Hereditary hemorrhagic telangiectasia
 * Herpes simplex virus esophagitis
 * Heterotopic pancreatic tissue
 * Idiopathic
 * Idiopathic thrombocytopenic purpura
 * Intestinal duplication a cause of haematemesis in children
 * Kaposi's sarcoma
 * Kasabach-Merritt syndromes
 * Leiomyoma
 * Lipoma
 * Lymphoma
 * Mallory-Weiss syndrome
 * Melanoma
 * Metastatic tumor to the upper GI tract
 * Munchausen syndrome by proxy a reason for recurrent haemtemesis in children
 * Nonsteroidal antiinflammatory drugs
 * Osler-Weber-Rendu syndrome
 * Parasites
 * Peptic ulcer disease
 * Pill-induced esophagitis
 * Polyp (hyperplastic, adenomatous, hamartomatous, etc)
 * Portal hypertension
 * Portal hypertensive gastropathy
 * Post gastric/duodenal polypectomy
 * Post-surgical anastamosis
 * Potassium chloride induced esophagitis or gastritis
 * Pseudomembranous esophagitis
 * Quinidine
 * Radiation-induced telangiectasia
 * Rift valley fever
 * Schistosomiasis
 * Sibutramine
 * Stress-induced ulcer
 * Systemic mastocytosis
 * Tetracycline (pill induced esophagitis)
 * Ticlopidine
 * Traumatic or post-surgical
 * Vasculitis
 * Von Willebrand disease
 * Watermelon stomach (gastric antral vascular ectasia)
 * Zollinger Ellison syndrome ( diffuse upper GI ulcerations)

Complete Differential Diagnosis of the Causes of Hematemesis
(By organ system)

General Management
The most common causes of upper GI bleeding include bleeding peptic ulcer disease, gastritis, and variceal bleed related to hepatic cirrhosis. This management section discusses general treatment of bleeding related to these common causes: In general, individuals who are at low risk for recurrent or life-threatening hemorrhage may be suitable for early hospital discharge or even outpatient care. All patients with hemodynamic instability or active bleeding should be admitted to an intensive care unit for resuscitation and close observation. Two large caliber peripheral catheters or a central venous line should be inserted for intravenous access. Gastroenterological consultation should be obtained. A surgical consultation can be obtained in high-risk patients. These patients should also receive packed red blood cell transfusions to maintain the hematocrit above 30 percent. In general, patients with upper GI bleeding (high and low risk patients) should be treated with an intravenous Protein pump inhibitor (PPI) at presentation until confirmation of the cause of bleeding, after which the need for specific therapy can be determined. Protein pump inhibitors are used because the most common causes of GI bleed are gastritis and peptic ulcer disease. Patients known to have cirrhosis who present with upper GI bleeding should receive antibiotics, preferably before endoscopy, as bacterial infections are present in up to 20 percent of these patients. Somatostatin may also reduce the risk of bleeding due to variceal and nonvariceal causes.

Prophylaxis Against Bleed From Variceal Hemorrhage and Ulceration
In these patients, the use of COX-2 selective inhibitor or a nonselective NSAID in combination with a PPI or misoprostol is indicated. In addition, patients with a history of uncomplicated or complicated peptic ulcers should be tested for H. pylori prior to beginning a NSAID or low dose aspirin. If present, H. pylori should be treated with appropriate therapy, even if it is believed that the prior ulcer was due to NSAIDs.
 * Primary prophylaxis against variceal hemorrhage is indicated because of high rate of bleeding from esophageal varices and the high mortality associated with bleeding. Prophylactic propranolol or nadolol therapy is the only cost-effective therapy in this setting.
 * Prophylaxis against stress ulceration maybe also indicated for ICU patients with any of the following characteristics:
 * 1) Coagulopathy
 * 2) Mechanical ventilation for more than 2 days
 * 3) History of GI ulceration or bleeding with the past year
 * 4) Two or more of the following risk factors — sepsis, ICU admission lasting >1 week, occult GI bleeding lasting ≥6 days, and glucocorticoid therapy.
 * Effective identification and antibiotic treatment of H.Pylori infections is also crutial in preventing complications including upper GI bleeding.
 * In regards to the prevention of NSAID-related peptic ulcer disease and complicating upper GI bleed: patients are at the highest risk for NSAID-induced GI toxicity when they have any of these risk factors:
 * 1) A history of an ulcer or GI hemorrhage
 * 2) Age >60
 * 3) High dosage of a NSAID
 * 4) Concurrent use of glucocorticoids
 * 5) Concurrent use of anticoagulants