Haematemesis

Probability diagnosis

Chronic peptic ulcer (stomach and duodenum) 50%

Acute gastric ulcers/erosions 20%

Oesophagitis (incl. GORD)

Mallory--Weiss (emetogenic) syndrome

Drugs: aspirin, NSAIDs, anticoagulants, clopidogrel, NOACs

Serious disorders not to be missed

Vascular:

• oesophageal varices

• blood dyscrasias, e.g. aplastic anaemia

• vascular malformation/angiodysplasia

• hereditary coagulopathy

Cancer:

• gastric or oesophageal

Other:

• chronic liver disease

Pitfalls (often missed)

Stomach ulcer

Swallowed blood (e.g. epistaxis)

Collagen diseases (e.g. scleroderma)

Rarities:

• ruptured oesophagus

• hereditary haemorrhagic telangiectasia

• scurvy

• ingested poisons (e.g. acid, alkali, arsenic)

• gastric antral vascular ectasia

Key history

• Nature of vomitus from fresh blood to ‘coffee grounds’

• Is bleeding arising from the mouth, nose or pharynx?

• Indigestion, heartburn or stomach pains

• Associated symptoms (e.g. weight loss, jaundice)

• Any bleeding problems

• Drug history including alcohol, NSAIDs, antiplatelet agents, warfarin, steroids

Key examination

• Patient’s general state including circulation, vital signs

• Abdominal examination and rectal examination

• Evidence of liver disease

Key investigations

• Upper GIT endoscopy diagnoses bleeding source in 80%

• FBE

• LFTs including © GT

• Helicobacter pylori tests

• Imaging (e.g. plain erect X-ray, as indicated)

Diagnostic tips

• Melaena occurs in 50% of cases of haematemesis.

• Oesophageal bleeding tends to give vomiting fresh blood.

• ‘Coffee grounds’ vomitus indicates contact with gastric acid.