Hematemesis K92.0

Hematemesis is the vomiting of a coffee-ground-like liquid or blood (Koop 2009). Hematemesis is always a medical emergency (Japp 2018).

The incidence of upper gastrointestinal tract bleeding is approximately 67 / 100,000 population and increases with age. Upper gastrointestinal bleeding is more common than lower gastrointestinal bleeding (DiGregorio 2023).

Hematemesis is a typical but not obligatory sign of upper gastrointestinal bleeding (Herold 2022). The source of bleeding is always above Treitz's ligament (Kasper 2015).

Hematemesis most commonly occurs with

- gastroduodenal ulcers

- esophageal varices

- Mallory- Weiss syndrome

Less commonly found as a cause are

- tumors of the gastrointestinal tract

- hemorrhagic gastritis

- iatrogenic bleeding after endoscopic surgery

- hematemesis during therapy with a combination of anticoagulants(Koop 2009).

It may also occur after ingestion of blood from the nose, mouth, throat, and lungs (Herold 2022).

The hemoglobin in the vomited blood may change to a coffee grounds-like hematin when it comes into contact with gastric acid during hematemesis. If the hematemesis is massive or if gastric acid is absent (e.g., due to therapy with PPI), the coffee grounds-like aspect is absent (Herold 2022).

Typical accompanying symptoms may facilitate the diagnosis in individual cases:

- bleeding after crampy, massive vomiting (in Mallory- Weiss syndrome)

- abdominal fasting pain with improvement on ingestion (in duodenal ulcer)

- uncharacteristic findings such as inappetence, anemia (Buchta 2008), B symptoms (Link 2023), etc. (in gastric carcinoma)

Physical examination

Attention should be paid to any:

- Liver skin signs such as spider nevi, palmar erythema, icterus (coagulation disorder in liver disease)

- ascites

- Lymph node metastases (e.g. Virchow's gland in gastric carcinoma)

- abnormalities of the rectal digital examination (Buchta 2008)

- Any indications of hemorrhagic shock (pulse, blood pressure, etc.) (Koop 2009).

In addition to laboratory chemical examinations, further diagnostic tests include, for example

- abdominal sonography

- Endoscopy of the gastrointestinal tract

- CT angiography (DiGregorio 2023)

- laryngoscopy

- bronchoscopy

- ESR (Buchta 2008)

- large blood count

- Coagulation parameters with prothrombin time (PTZ), activated partial thromboplastin time(aPTT), International Normalized Ratio(INR)

- lactate

- Liver function tests (DiGregorio 2023)

- Cross blood (Link 2023)

- Placement of large-volume venous accesses for the purpose of volume administration or transfusions

- Erythromycin 250 mg i.v. if bleeding intensity is likely to be high, such as in the case of coagulum in the tamponade stomach (Koop 2009).

Further therapy depends on the cause of hematemesis.

The prognosis for hematemesis is generally worse the longer the volume deficiency persists (Fetzner 2014).

In addition, the prognosis depends on the cause of hematemesis. Mallory- Weiss syndrome, for example, has a good prognosis (Girndt 2023).

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