Why vomiting blood matters
Upper gastrointestinal bleeding is common and can be torrential. Resuscitation comes first; the history then tells you the likely source, which decides what to start before endoscopy and how urgently he needs it.
What to ask in the history
- How much blood, what it looked like (fresh red or coffee grounds), how many times
- Retching or vomiting before the blood appeared
- Black stools: how long
- Dizziness, fainting, breathlessness, chest pain
- Alcohol: how much, for how long
- Known liver disease, previous bleeds or endoscopies
- Medicines: aspirin and other painkillers, blood thinners, steroids, and any that slow the heart
- Indigestion, weight loss, difficulty swallowing
Red flags
- Ongoing vomiting of blood
- Fast pulse or low blood pressure (a medicine that slows the heart can hide a fast pulse)
- Fainting or confusion
- Signs of chronic liver disease
- Heart, kidney or liver disease alongside
What to examine
- Airway (risk of aspiration), breathing, circulation, conscious level
- Pulse, blood pressure, capillary refill, temperature of hands and feet
- Signs of chronic liver disease: jaundice, spider naevi, palmar erythema, a flap, ascites, an enlarged spleen
- Abdomen for tenderness
- Rectal examination for black stool
First investigations
- Full blood count, blood group and crossmatch
- Clotting
- Urea and creatinine, electrolytes, liver function
- Blood gas with lactate
- A pre-endoscopy risk score
- Upper GI endoscopy once he is resuscitated
Differential diagnosis of vomiting blood
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Ulcers and inflammation
- Peptic ulcer
- Erosive gastritis or oesophagitis
Raised pressure in the portal system
- Oesophageal or gastric varices
- Portal hypertensive gastropathy
Tears and other lesions
- Mallory-Weiss tear
- Upper GI cancer
- Vascular lesions
Not from the stomach
- Swallowed blood from the nose or mouth
- Blood coughed up from the lungs
Common mistakes
- Being reassured by a normal pulse in a patient on a medicine that slows the heart.
- Sending him for endoscopy before he is resuscitated.
- Forgetting to check and correct his clotting.
- Transfusing without a plan; follow the hospital's transfusion protocol.