Rapid Diagnosis: Vomiting Blood

The dispatcher reports that the patient is vomiting blood. Hemataemesis if you want to be technical about it. It could be a whole bunch of things right? … Well yes it could. Before you e-mail me to say that you can’t believe I missed Bolivian Hemorrhagic Fever, here’s one web site that lists 113 possibilities.

But if you want to play the numbers, it’s going to be one of four things. And if you want to play “stump your partner” you can narrow it down quite a bit based on your patients age and disposition.

There are four things that tend to cause a person to vomit blood. Before you click on the little “read more” link, how many can you name?

Sure, it could be Mucormycosis or rattlesnake poisoning, but before you go there consider:

Esophageal Varices

The blood supply to the esophagus is primarily drained through the esophageal veins. However, some of that blood supply drains through superficial veins that line the interior of the esophagus. These veins drain into the portal vein and create a problem when the patient develops portal hypertension, as seen frequently in our alcoholic populations with liver cirrhosis.

Over time those minute esophageal veins can swell 100 to 200 times there original size and eventually rupture, causing gastric irritation, vomiting of frank red blood and hypovolemic shock.

This one gets a fair amount of play time in our training because esophageal variceshappen to be a contraindication to the insertion of any of those airways that seal the esophagus. Use of the EGTA, the King Tube, the Combitube or any of the “dual lumen” airway designsinvolves inflating a balloon in the patients esophagus. These devices are contraindicated in patients with a known history of esophageal varices.

Gastritis

Inflammation of the lining of the stomach is known as Gastritis. This condition also has two close cousins, esophagitis and duodenitis. These inflammations are usually the result of alcohol consumption and excessive use of NSAIDs like Ibuprofen and Naproxen Sodium.

Blood from gastritis can be frank or coffee ground in nature and is usually associated with pain in the epigastrium sometimes radiating through to the back.

Bleeding Peptic Ulcers

Peptic ulcers bleed for two reasons. The ulcer itself can bleed into the stomach, irritating the gastric lining or recurring vomitus from ulcers can damage the lining of the esophagus and the bleeding can originate there. Depending on the location of origin, vomitus can be coffee ground, light or dark red.

By the time ulcers produce bloody vomitus, the patient is usually aware of their peptic ulcer history or have been treating associated symptoms at home with antacids for some time. The will most likely have a history of GERD, alcoholism or chronic NSAID use.

 Mallory – Weiss Syndrome

Also known as a Mallory – Weiss tear, this condition was first observed in 15 alcoholic patients and documented by the two physicians who give the syndrome its name. The Mallory Weiss tear is a tear in the mucous membrane of the esophagus where it joins to the stomach. It is most frequently caused by excessive vomiting or coughing.

This condition is found primarily in the alcoholic patient populations (Is anyone else seeing a pattern here.) as well as patients with eating disorders. Patients usually describe normal vomiting episodes transitioning to bloody vomitus or extreme coughing fits. This bleeding tends to be pain free.

Mallory – Weiss tears commonly heal without intervention but some require endoscopic interventions.

Remember to oxygenate these patients and monitor for hypovolemia. Help them protect their airway and be ready to suction and take over if they decompensate. Keep in mind that we shouldn’t be using dual lumen airway devices that rest in the esophagus with these patients.

If you have the ability, have large bore IVs in place to replace lost blood if necessary and remember that not all upper GI bleeding presents with vomiting. Dark, tarry, melena type stool is also an indication of upper GI bleeding.

So there you have it! The next time you walk in on a patient vomiting blood you can nail the cause and treat accordingly. (Or, perhaps, vice versa?)

Wear those gloves people,

Steve

Comments

  1. Thanks for that post 🙂

  2. What about pulmonary embolism? Did you eliminate that based on the fact that we’re seeing straight up blood and not sputum?

  3. There is another cause for esophegal varices other than alcoholic cirrhosis, and that is primary biliary cirrhosis, an autoimmune disease. 90% afflicted are middle-aged or older women. Primary because not secondary, biliary because the bile ducts are being destroyed, cirrhosis because that is the end result. Esophageal varices resulting from portal hypertension are one of the most feared (prior to liver failure) co-conditions by patients with PBC. So if you pick up a middle aged woman with esophageal varices who tells you she doesn’t drink, she may well have PBC, whether she knows it yet or not.

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