Haematemesis (Vomiting Blood)

What is haematemesis?

Haematemesis means vomiting blood. It is usually a sign of bleeding arising from the gullet, the stomach or the duodenum.

The blood brought up may be bright red or dark red. When blood has remained in the stomach for a while, the action of the stomach acid darkens it and it may take on the appearance of coffee grounds.

Haematemesis is not a disease in itself. It is a sign of underlying bleeding and its cause must always be investigated.

Vomiting blood requires emergency medical assessment.

What are the commonest causes?

Many diseases can cause bleeding in the upper digestive tract.

The important causes include:

• Ulcer of the stomach or duodenum,
• Varices of the gullet or the stomach,
• Inflammation and erosions in the lining of the stomach,
• Oesophagitis,
• Tears that can occur at the junction of the gullet and the stomach after violent vomiting (Mallory-Weiss tear),
• Tumours of the stomach or the gullet,
• Certain vascular lesions.

Aspirin and some painkillers of the NSAID group can increase the risk of ulcers and bleeding in the stomach and duodenum.

Blood-thinning drugs may in some patients contribute to making an existing bleed more serious.

What does haematemesis look like?

The appearance varies with the site of the bleeding, its speed and how long the blood has stayed in the stomach.

Bright red blood

May be seen in active, rapid bleeding. In large amounts in particular it may signal serious blood loss.

Dark red blood

Blood that has remained in the stomach for a while may appear darker.

Coffee-ground appearance

When blood meets stomach acid it may darken, and the vomit may resemble coffee grounds.

Coffee-ground vomiting should also be regarded as gastrointestinal bleeding and taken seriously.

What other symptoms may occur?

Haematemesis may be accompanied by:

• Black, shiny or tarry stools (melaena),
• Weakness,
• Dizziness,
• Palpitations,
• Cold sweating,
• Pallor,
• A fall in blood pressure,
• Breathlessness,
• Fainting.

When blood loss is great the circulation may fail and shock may develop.

What should a person vomiting blood do?

It is not right for a person vomiting blood to wait at home for the bleeding to settle.

The patient should be assessed at an emergency department.

The situation may be more serious where there is vomiting of large amounts of blood, recurrent bleeding, black stools, fainting, marked weakness, cold sweating or breathlessness.

The patient should tell the medical team about the drugs being taken, particularly aspirin, painkillers and blood thinners.

Whether prescribed aspirin or blood thinners should be stopped is a decision for the doctor, weighing the patient’s bleeding risk against their cardiovascular risk.

How is the diagnosis made?

The first aim is not merely to find the source of the bleeding. What is assessed first is how far the blood loss has affected the patient’s circulation.

Blood pressure, pulse and general condition are checked. Blood tests may examine the haemoglobin, the blood cells, the clotting system and kidney and liver function.

Where necessary, intravenous access is obtained and fluids and blood products given.

Gastroscopy

One of the most important methods of diagnosis and treatment in upper gastrointestinal bleeding is gastroscopy.

Endoscopic examination of the gullet, stomach and duodenum allows:

• The source of the bleeding to be found,
• Whether the bleeding is continuing to be seen,
• The risk of a further bleed to be assessed,
• The bleeding to be stopped during the same procedure where needed.

Once the patient’s general condition has been corrected, endoscopy is generally aimed for within the first 24 hours in most acute upper gastrointestinal bleeds.

The timing may vary with the type of bleeding and the patient’s condition. In patients in whom variceal bleeding is suspected in particular, a different and more urgent approach may be needed.

How is bleeding stopped at endoscopy?

Different endoscopic methods may be used depending on the cause.

In bleeding ulcers:

• Closing the bleeding vessel with special clips,
• Coagulating the vessel by thermal methods,
• Injection treatments,
• In some cases haemostatic powder or other advanced endoscopic methods

may be used.

In variceal bleeding the treatment is different. For varices of the gullet, endoscopic band ligation is one of the important methods.

What if endoscopy cannot stop the bleeding?

A significant proportion of upper gastrointestinal bleeds can now be brought under control by endoscopic means.

If bleeding continues or recurs, endoscopic treatment may be repeated.

If bleeding still cannot be controlled, interventional radiology can find the bleeding vessel at angiography and close it by embolisation.

Surgery is needed less often now, but may be required for some bleeds that cannot be controlled by other means.

What is the outlook?

The outlook depends on the cause and the amount of the bleeding, the patient’s age, any accompanying illnesses and how quickly treatment is reached.

Bleeding from a small erosion and bleeding from a large ulcer vessel or from an oesophageal varix do not carry the same risk.

Modern endoscopic treatments, drugs and interventional radiology mean that the great majority of upper gastrointestinal bleeds can be successfully controlled.

Once the first bleed has been stopped, however, treating the cause of the bleeding and reducing the risk of a further bleed also matter.

In bleeding from an ulcer, for instance, if H. pylori is found, eradication treatment should be given and the clearance of the bacterium confirmed.

When should emergency help be sought?

Emergency medical care should be sought without delay if any of the following is present:

• Vomiting bright red blood,
• Vomiting dark blood,
• Coffee-ground vomiting,
• Vomiting blood together with black tarry stools,
• Dizziness or fainting,
• Marked weakness and cold sweating,
• Palpitations or breathlessness.

A small apparent amount of blood is no guarantee that the bleeding is not serious.

Currency: This information was prepared for patients taking account of current international endoscopy guidelines on the diagnosis and treatment of acute upper gastrointestinal bleeding.

This content is for general information. Vomiting blood is a sign requiring emergency medical assessment.