# Vomiting blood at 2 a.m. in a 52-year-old: a live emergency case

> A live emergency case for medical students: a 52-year-old vomiting fresh blood at 2 a.m. Resuscitation first, what to ask, signs to look for, the first tests and the causes of upper GI bleeding.

- Gastroenterology · Intermediate · about 20 minutes · live emergency
- Web page: https://www.medikarya.in/case-studies/52-year-old-man-vomiting-blood-at-2-am
- Work up this patient: https://www.medikarya.in/case-studies/52-year-old-man-vomiting-blood-at-2-am

## How the patient presents

A 52-year-old man comes to emergency at 2 a.m. still vomiting large amounts of fresh red blood, with black stools for two days. He takes atenolol for blood pressure and drinks a bottle of wine a day.

## 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.

---

A study guide for medical students, not medical advice. Follow your institution's protocols in practice.