Haematemesis
Gastroenterology
Introduction
Author: Sarosh Ibrahim
Haematemesis, or vomiting blood, is a critical clinical symptom that requires a structured and thorough history-taking approach. Key principles include identifying the onset, quantity, and nature of the bleeding (fresh red blood vs. coffee-ground vomitus), associated symptoms (e.g., melena, dizziness, abdominal pain), and potential underlying causes such as peptic ulcer disease, variceal bleeding, or malignancy. A detailed medication and alcohol history is essential, alongside assessing risk factors like liver disease or NSAID use. Rapid identification of red flags, such as hemodynamic instability, helps guide urgent management decisions.
WIPER
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Presenting Complaint
1. Onset:
When did the vomiting blood begin?
Was it sudden or gradual?
2. Nature and Quantity
Bright red blood (fresh) or coffee-ground appearance (digested)?
Estimate the amount of blood vomited.
3. Character of the cough:
Is it dry or productive?
If productive, describe the sputum (colour, volume,
consistency, odour).
Is there haemoptysis (blood-streaked or frank blood)?
4. Associated Symptoms:
Gastrointestinal:
Abdominal pain, bloating, nausea, or dysphagia.
Systemic:
Dizziness, fatigue, pallor, sweating, or syncope (suggesting hypovolaemia).
Other:
Melaena (black tarry stools), diarrhoea, or fever.
5. Triggers:
Recent NSAID or aspirin use, alcohol intake, or vomiting episodes.
7. Exacerbating Factors:
Does anything worsen the symptoms? (e.g., food, alcohol, lying flat).
8. Relieving Factors:
Has anything improved the symptoms?
9. Progression:
Has the frequency or severity increased?
How has it affected daily life (work, mobility, or appetite)?
10. Severity:
Rate severity on a scale of 1-10 (e.g., mild, moderate, severe) and quantify blood loss if possible.
ICE: Ideas, Concerns, Expectations
Ideas: What do they think caused the bleeding?
Concerns: Are they worried about anything specific?
Expectations: What are they hoping for in terms of treatment?
Past Medical History
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Medications
Current medications and recent changes including over the counter drugs.
NSAIDs, aspirin, anticoagulants, steroids.
Recent changes in medication or over-the-counter drugs.
Family History
Family history of gastrointestinal disorders, liver disease, or bleeding disorders.
Social History
Smoking History: Calculate pack-years history
Alcohol Consumption: How many units per week?
Occupation: Stress or dietary habits that may predispose to GORD or ulcers.
Recreational Drugs: Use of substances that may affect liver function.
Differential Diagnosis
Haematemesis can be caused by the following causes:
Upper GI Causes:
Peptic ulcer disease
Oesophageal varices
Mallory-Weiss tear
Oesophagitis or gastritis
Systemic Causes:
Coagulopathies (e.g., thrombocytopenia, anticoagulant use).
Portal hypertension due to liver cirrhosis.
Malignancies:
Gastric or oesophageal cancer.
Management
Bedside:
Physical examination to check for
Assess for signs of hypovolaemia (pallor, tachycardia, hypotension, capillary refill time).
Abdominal examination: Inspect for distension, tenderness, or hepatomegaly.
Other signs include Jaundice, spider naevi, or palmar erythema (signs of chronic liver disease).
Laboratory:
Blood Tests:
Full blood count (FBC) – anaemia or thrombocytopaenia
Urea: elevated in upper GI bleeding.
Coagulation profile (PT/INR, aPTT): assess clotting status.
Liver function tests (LFTs): to rule out liver disease.
Cross-match for blood transfusion if needed.
Imaging and Special Tests:
Abdominal ultrasound (if liver disease is suspected)
Endoscopy: Gold standard to identify the bleeding source.
Management Plan
1.Immediate Stabilisation:
Ensure airway, breathing, and circulation (ABC).
Insert two large-bore cannulas for IV access.
Fluid resuscitation and/or blood transfusion as needed.
2. Definitive Treatment:
Endoscopic intervention (e.g., banding for varices, haemostasis for ulcers).
Address underlying cause (e.g., eradicate H. pylori in peptic ulcer).
3. Medications:
Proton pump inhibitors (PPIs).
Antibiotics (if variceal bleeding suspected).
4. Monitoring:
Regular vital signs and haemoglobin checks.
5. Referral:
Gastroenterology for endoscopic management.
Surgery if bleeding is uncontrolled.