Vomiting Blood
This presentation may vary from a few red streaks in gastric fluid to copious quantities of bright red blood. Blood static in the stomach for a few hours will change to look dark and granular, like coffee grounds. Always do a full urgent assessment, and be prepared for the sudden need for resuscitation.
Differential diagnosis
Common Diagnoses
- Peptic Ulcer (PU)/Acute Gastritis
- Mallory–Weiss (M–W) Tear
- Oesophageal Varices (Cirrhosis, Usually Alcoholic)
- Malignancy: Oesophagus or Stomach
- GORD
Occasional Diagnoses
- Swallowed Blood (Nose Bleeds Obvious, Haemoptysis Less So)
- Foreign Body or Mediastinal Tumour Perforating Oesophagus and Aorta (Including Aneurysm)
- Haemobilia (Blood in Bile)
- Ingested Poisons: Corrosive Acid and Alkali, Arsenic
- Blood Dyscrasias (e.g. Thrombocytopenia, Leukaemia, Haemophilia, Aplastic Anaemia)
Rare Diagnoses
- Ruptured Oesophagus (Acute Vomiting or Trauma)
- Spurious: Deliberate Swallowing and Vomiting of Blood (Munchausen’S Syndrome)
- Gallstone Perforation of Duodenum
- Scurvy
- Polyarteritis Nodosa, Systemic Lupus Erythematosus (SLE)
Ready reckoner
Key distinguishing features of the most common diagnoses
| PU | M–W Tear | Varices | Cancer | Oesophagitis | |
|---|---|---|---|---|---|
| History of Weight Loss | Possible | No | Possible | Yes | No |
| Preceded by Vomiting | Possible | Yes | No | No | No |
| Preceded by Melaena | Possible | No | Possible | Possible | Possible |
| Severe Pain | Yes | Possible | No | Possible | Yes |
| Signs of Shock Likely | Yes | No | Yes | Possible | No |
Possible investigations
- These will be done acutely in hospital, or in general practice after an episode of haematemesis when urgent admission is not indicated.
- FBC: Essential for assessment of the degree of blood loss. A normal Hb does not exclude a serious bleed as haemodilution may take several hours. Will also reveal blood dyscrasias. Raised platelets associated with oesophageal or stomach cancer.
- Upper gastrointestinal (GI) endoscopy is the gold standard for finding the cause of the bleed and biopsy of suspicious lesions.
- Helicobacter testing: In the presence of peptic ulceration.
- LFT and γGT to assess liver function. Alcohol is a significant contributory factor in many cases.
- Plain erect abdominal X-ray (in hospital) useful to look for signs of viscus perforation (air under diaphragm) and, rarely, an ectopic gallstone.
Top Tips
- Take a careful history – patients often confuse vomiting up and coughing up blood.
- If about to visit, ask the patient not to dispose of the evidence – viewing the vomit is worth a thousand words of history.
- Don’t forget the relevance of the patient’s drug history – non-steroidal anti-inflammatory drugs (NSAIDs), steroids and warfarin may all be associated with acute gastric erosions.
Red Flags
- Tachycardia may be the only physical sign of a significant GI bleed.
- In all acute cases, admit unless the patient is perfectly well and the cause obvious and insignificant (e.g. swallowed blood or very minor Mallory–Weiss tear).
- The patient may not realise the significance of coffee-ground vomit or melaena – enquire specifically about these symptoms.
- Troisier’s sign (enlargement of the left supraclavicular node) strongly suggests malignancy.
- Oesophageal varices account for only 5% of cases, but 80% of mortality. Call for an ambulance immediately and secure intravenous (IV) access if possible.