Upper Gastrointestinal Bleeding (Hematemesis)

What is hematemesis?

Hematemesis is the vomiting of blood. The bleeding is usually from the upper gastrointestinal (GI) tract. This means the bleeding may be from the esophagus (the tube that connects the mouth and stomach), the stomach, or the upper small intestine (duodenum).

How does it occur?

The most common cause of upper GI bleeding is an ulcer in the stomach or small intestine.

Irritation of the stomach (gastritis) or esophagus (esophagitis) can also cause bloody vomit. Medicines such as aspirin, ibuprofen, and naproxen are common causes of stomach and esophagus irritation.

Another common cause of bleeding is liver disease. When the liver has scars from cirrhosis, the veins around the esophagus become swollen, like varicose veins of the legs. The veins may bleed suddenly after you cough or vomit, or they may bleed for no apparent reason.

Sometimes the esophagus bleeds because it is torn. These tears may happen after forceful coughing or vomiting, especially, for example, after a severe bout of stomach flu or from vomiting after drinking too much alcohol.

It is unusual for cancers of the stomach and esophagus to cause large amounts of bloody vomit.

What are the symptoms?

Vomiting blood can be a very frightening experience. In mild cases, you may notice small amounts of bright, red blood or dark brown or black material that looks like coffee grounds in your vomit. If the bleeding is severe, you may keep vomiting large amounts of bright red blood.

You may have other symptoms, depending on the cause of the vomiting of blood. These symptoms may be:

• heartburn
• stomach pain
• dark, black, tarry bowel movements.

Black, tarry stools may mean that you have had bleeding from your stomach or intestines for some time. Blood that passes through the intestines is digested and turns black.

How is it diagnosed?

If the bleeding is mild and not frequent, your health care provider will first ask about your personal and family medical history. You will have a physical exam. You may also have:

• blood tests
• a test to look for blood in your bowel movements
• an x-ray of your esophagus or stomach.

If these tests do not show a cause of bleeding and your symptoms continue or if you have more severe bleeding, you may have an upper endoscopy. First your provider will give you medicine to sedate you. Then he or she will insert a thin, flexible tube with a tiny camera through your mouth, into your esophagus and stomach, and into the upper small intestine to look for causes of bleeding. The endoscope can be used to look for varicose veins of the esophagus, irritation of the lining of the esophagus or stomach organs, or an ulcer.

How is it treated?

If the bleeding is severe, you will be treated in the emergency room and hospital, maybe even in the intensive care unit. The first goal of treatment is to stop the bleeding. You need to have enough fluids and blood to maintain a normal blood pressure to keep you alert and keep your organs healthy (such as your brain, heart, and kidneys). You will have an IV line for intravenous fluids and medicines. You may also be given oxygen with a small short tube in your nose. You will probably have a nasogastric tube, which is a slim, flexible plastic tube that passes through your nose down into your stomach. Your health care provider can give you medicines through the nasogastric tube to help stop the bleeding. Your provider can also use the tube to get samples of stomach fluids so he or she can tell if the bleeding has stopped.

If you have severe bleeding and it can't be stopped, a special tube with a balloon on the end of it may be inserted into your esophagus. Once in place, the balloon can be blown up so that it presses on the area of bleeding to stop it. You may need emergency surgery to stop the bleeding.

Depending on how fast your bleeding stops and why you are bleeding in the first place, you will be in the hospital at least 1 day or more. You will have treatment for the underlying cause of the bleeding as well.

Whether the bleeding is mild or severe, you will have blood tests to help measure how much blood you have lost and to see if your blood has problems clotting. The tests will also help determine why you are having the bleeding. You may have one or more endoscopies to look for the cause and to see if the bleeding is likely to restart.

If the bleeding is mild (occasional or small amount), the treatment will depend on the cause of the bleeding:

• Irritating medicines will need to be discontinued.
• Forceful vomiting will be treated with antinausea and vomiting drugs.
• Gastritis and ulcers will be treated with medicine. You may need to stop smoking or stop drinking alcohol.
• Liver disease will be treated according to its cause.
• Varicose veins of the esophagus may need to be removed with surgery or with chemicals applied directly to them.
• For all cases, your provider will recommend a soft (nonirritating) diet.

How can I take care of myself?

• Follow your health care provider's instructions carefully. Make sure you take all prescribed medicines and follow any special diets your provider recommends.
• If the bleeding was caused by alcohol abuse, you need to follow your health care provider's recommendations for stopping drinking.
• Keep all follow-up appointments with your health care provider.
• Make sure you know what to do if the bleeding starts again.

How can I help prevent GI bleeding?

Prompt treatment of the frequent causes of vomiting blood may prevent it from ever occurring. See your health care provider if you have:

• symptoms of ulcers or irritation of the stomach or esophagus, such as stomach pain, heartburn, or acid indigestion
• black, tarry bowel movements.

If you drink too much alcohol, you are at high risk of developing scarring of the liver (cirrhosis) and problems with your esophagus and stomach that may cause sudden, severe bleeding. You need to get help with your drinking problem.