CHAPTER Practical Approach to Blood Vomiting 35 Jatinder K Mokta INTRODUCTION require admission for resuscitation and treatment. Hematemesis is defined as vomiting of blood, which is INITIAL EVALUATION (FIGURE 1) indicative of bleeding from the esophagus, stomach, or The initial evaluation of the patient with bloody vomiting duodenum.1 Hematemesis includes vomiting of bright involves an assessment of the hemodynamic stability and red blood, suggestive of recent or ongoing bleeding, and resuscitation, and if necessary diagnostic studies (usually dark material (coffee-ground emesis), which suggests endoscopy) with the goal of both diagnoses and when bleeding that had stopped some time ago. Hemetemesis possible, treatment of the specific disorder. is often accompanied by melena which is black tarry stool that results from degradation of blood to hematin or other Evaluation of the patient includes a history, physical hemochromes by intestinal bacteria. examination, laboratory tests, and in some cases, nasogastric lavage. The information gathered as a part Gastrointestinal bleeding can be classified as overt, occult of initial evaluation is used to guide decisions regarding or obscure. triage, resuscitation, empiric medical therapy and Overt Gastro-Intestinal (GI) bleeding is visible and can diagnostic testing. present in the form of hematemesis, “coffee-ground” Past Medical History - Patients should be asked about emesis, melena, or hematochezia. Occult bleeding refers to prior episodes of upper GI bleeding, since up to 60 percent bleeding which is not clinically visible as it is microscopic of patients bleed from the same lesion.2 In addition, the bleeding. Obscure GI bleeding refers to recurrent bleeding patient’s past medical history should be reviewed to in which a source is not identified after upper endoscopy identify important co-morbid conditions. and colonoscopy. It may be either overt or occult. Potential bleeding sources suggested by a patient’s past Depending upon the site, gastrointestinal bleeding can medical history include: be classified as either upper or lower GI beed. Upper GI bleeding is hemorrhage originating from the esophagus • Varices or portal hypertensive gastropathy in a to the ligament of Treitz, at the duodenojejunal flexure patient with a history of liver disease or alcohol and lower GI bleeding originates from a site distal to the abuse. ligament of Treitz. • Peptic ulcer disease in a patient with a history Hemetemesis is a manifestation of acute severe upper of Helicobacter pylori, nonsteroidal anti- Gastro-Intestinal bleed. Acute GI bleeding is a major inflammatory drug (NSAIDs) use, or smoking and cause of hospital admissions in the United States, which epigastric discomfort. is estimated at 300000 patients annually. Upper GI tract • Cameron’s erosions in patient with history of large bleed is approximately four times more common than hiatal hernia. that of lower GI tract and is a major cause of morbidity • Aorto-enteric fistula in a patient with a history of and mortality. Acute GI bleeding is more common in an abdominal aortic aneurysm or an aortic graft. men than women and its prevalence increases with age. The most common causes of acute upper GI bleeding are • Angiodysplasia in a patient with renal disease, peptic ulcer disease including from the use of aspirin and aortic stenosis, or hereditary hemorrhagic other non-steroidal anti-inflammatory drugs (NSAIDs), telangiectasia. variceal hemorrhage, Mallory-Weiss tear and neoplasms • Malignancy in a patient with a history of smoking, including gastric cancers. Other relatively common causes alcohol abuse, or H. pylori infection. include esophagitis, erosive gastritis/duodenitis, vascular ectasias and Dieulafoy’s lesions.1 Esophageal varices and • Marginal ulcers (ulcers at an anastomotic site) in a peptic ulcer disease are major causes of upper GI bleeding patient with a gastroenteric anastomosis. in both Eastern and Western societies. Comorbid illnesses may influence patient management in Severe GI bleed is defined as documented gastrointestinal the setting of an acute upper GI bleed. Comorbid illnesses bleeding accompanied by shock or orthostatic may: hypotension, and a decrease in the hematocrit value by at • Make patients more susceptible to hypoxemia least 6% or a decrease in the hemoglobin level of at least (eg, coronary artery disease, pulmonary disease). 2 g/dL, or requires transfusion of at least two units of Such patients may need to be maintained at higher packed red blood cells.1 Patients with severe GI bleeding hemoglobin levels than patients without these 188 disorders. chemistries, liver tests, and coagulation studies. In • Predispose patients to volume overload in the addition, serial electrocardiograms and cardiac enzymes setting of fluid resuscitation or blood transfusions may be indicated in patients who are at risk for a (eg, renal disease, heart failure). Such patients myocardial infarction, such as older adults, patients with may need more invasive monitoring during a history of coronary artery disease, or patients with resuscitation. symptoms such as chest pain or dyspnea. • Result in bleeding that is more difficult to control The initial hemoglobin in patients with acute upper GI (eg, coagulopathies, thrombocytopenia, significant bleeding will often be at the patient’s baseline because hepatic dysfunction). Such patients may need the patient is losing whole blood. With time (typically transfusions of fresh frozen plasma or platelets. after 24 hours or more) the hemoglobin will decline as the blood is diluted by the influx of extravascular fluid • Predispose to aspiration (eg, dementia, hepatic into the vascular space and by fluid administered during encephalopathy). Endotracheal intubation should resuscitation. It should be kept in mind that overhydration be considered in such patients. can lead to a falsely low hemoglobin value. The initial Symptom assessment — Patients should be asked about hemoglobin level is monitored every two to eight hours, symptoms as part of the assessment of the severity of the depending upon the severity of the bleed. bleed and as a part of the evaluation for potential bleeding GASTROENTEROLOGY Patients with acute bleeding should have normocytic red sources. Symptoms that suggest the bleeding is severe blood cells. Microcytic red blood cells or iron deficiency include orthostatic dizziness, confusion, angina, severe anemia suggest chronic bleeding. Because blood is palpitations, and cold/clammy extremities. absorbed as it passes through the small bowel and patients Specific causes of upper GI bleeding may be suggested by may have decreased renal perfusion, patients with acute the patient’s symptoms:3 upper GI bleeding typically have an elevated blood urea nitrogen (BUN)-to-creatinine or urea-to-creatinine ratio • Peptic ulcer: Epigastric or right upper quadrant (>20:1 or >100:1, respectively).4,5 The higher the ratio, the pain more likely the bleeding is from an upper GI source.4 • Esophageal ulcer: Odynophagia, gastroesophageal reflux, dysphagia. GENERAL MANAGEMENT (FIGURE 2) Triage — Resuscitation of a hemodynamically unstable • Mallory-Weiss tear: Emesis, retching, or coughing patient begins with assessing and addressing the ABCs prior to hematemesis. (ie, airway, breathing, circulation) of initial management. • Variceal hemorrhage or portal hypertensive All patients with hemodynamic instability (shock, gastropathy: Jaundice, weakness, fatigue, anorexia, orthostatic hypotension) or active bleeding (manifested abdominal distention. by hematemesis, bright red blood per nasogastric tube, • Malignancy: Dysphagia, early satiety, involuntary or hematochezia) should be admitted to an intensive weight loss, cachexia. care unit for resuscitation and close observation with automated blood pressure monitoring, electrocardiogram Physical examination — The physical examination is a key monitoring, and pulse oximetry. Foley catheter placement component of the assessment of hemodynamic stability. 3 is mandatory to allow a continuous evaluation of the Signs of hypovolemia include: urinary output as a guide to renal perfusion. • Mild to moderate hypovolemia: Resting Other patients can be admitted to a regular medical tachycardia. ward, all admitted patients with the exception of low- • Blood volume loss of at least 15 percent: Orthostatic risk patients receive electrocardiogram monitoring. hypotension (a decrease in the systolic blood Outpatient management may be appropriate for some pressure of more than 20 mmHg and/or an increase low-risk patients. in heart rate of 20 beats per minute when moving General support — Patients should receive supplemental from recumbency to standing). oxygen by nasal cannula and should receive nothing per • Blood volume loss of at least 40 percent: Supine mouth. Two large caliber (16 gauge or larger) peripheral hypotension. intravenous catheters or a central venous line should be The presence of abdominal pain, especially if severe inserted who need close monitoring during resuscitation. and associated with rebound tenderness or involuntary Elective endotracheal intubation in patients with ongoing guarding, raises concern for perforation. If any signs of an hematemesis or altered respiratory or mental status may acute abdomen are present, further evaluation to exclude facilitate endoscopy and decrease the risk of aspiration. a perforation is required prior to endoscopy. Fluid resuscitation — Adequate resuscitation and Finally, as with the past medical history, the physical