STUDY - Technical - New Dacian's Medicine
Hematemesis
(Classical / Allopathic Medicine)
Hematemesis, the
vomiting of blood, usually indicates GI bleeding above the
ligament of Treitz, which suspends the duodenum at its
junction with the jejunum. Bright red or blood-streaked
vomitus indicates fresh or recent bleeding. Dark red, brown,
or black vomitus (the color and consistency of coffee grounds)
indicates that blood has been retained in the stomach and
partially digested.
Although
hematemesis usually results from a GI disorder, it may stem
from a coagulation disorder or from a treatment that irritates
the GI tract. Swallowed blood from epistaxis or oropharyngeal
erosion may also cause bloody vomitus.
Hematemesis is
always an important sign, but its severity depends on the
amount, source, and rapidity of the bleeding. Massive
hematemesis (vomiting of 500 to 1,000 ml of blood) may rapidly
be life-threatening. Hematemesis may be precipitated by
straining, emotional stress, anti-inflammatory therapy, or
alcohol consumption. (See Rare causes of hematemesis.)
ALERT:
If the patient has massive hematemesis:
- quickly check his vital signs
- look for signs of shock, such as tachypnea, hypotension, and tachycardia
- place him in a supine position and elevate his feet 20 to 30 degrees
- prepare for emergency endoscopy, if necessary.
If the patient's hematemesis isn't immediately life-threatening, perform a focused assessment.
If the patient has massive hematemesis:
- quickly check his vital signs
- look for signs of shock, such as tachypnea, hypotension, and tachycardia
- place him in a supine position and elevate his feet 20 to 30 degrees
- prepare for emergency endoscopy, if necessary.
If the patient's hematemesis isn't immediately life-threatening, perform a focused assessment.
HISTORY:
Ask the patient when the hematemesis began. Has he ever had it before?
Ask the patient to describe the amount, color, and consistency of the vomitus.
Ask the patient if he has bloody or black tarry stools and whether hematemesis is usually preceded by nausea, flatulence, diarrhea, or weakness.
Ask the patient if he recently had bouts of retching with or without vomiting.
Ask the patient about a history of ulcers and liver and coagulation disorders.
Ask the patient about his alcohol intake and if he regularly takes aspirin or another nonsteroidal anti-inflammatory drug (NSAID), such as phenylbutazone or indomethacin.
Ask the patient when the hematemesis began. Has he ever had it before?
Ask the patient to describe the amount, color, and consistency of the vomitus.
Ask the patient if he has bloody or black tarry stools and whether hematemesis is usually preceded by nausea, flatulence, diarrhea, or weakness.
Ask the patient if he recently had bouts of retching with or without vomiting.
Ask the patient about a history of ulcers and liver and coagulation disorders.
Ask the patient about his alcohol intake and if he regularly takes aspirin or another nonsteroidal anti-inflammatory drug (NSAID), such as phenylbutazone or indomethacin.
Rare causes of
hematemesis
Two rare disorders commonly cause hematemesis. Malaria produces this and other GI signs, but its most characteristic effects are chills, fever, headache, muscle pain, and splenomegaly. Yellow fever causes hematemesis as well as sudden fever, bradycardia, jaundice, and severe prostration.
Two relatively common disorders may cause hematemesis in rare cases. When acute diverticulitis affects the duodenum, GI bleeding and resultant hematemesis occur with abdominal pain and fever. With GI involvement, secondary syphilis can cause hematemesis; more characteristic signs and symptoms include a primary chancre, rash, fever, weight loss, malaise, anorexia, and headache.
Two rare disorders commonly cause hematemesis. Malaria produces this and other GI signs, but its most characteristic effects are chills, fever, headache, muscle pain, and splenomegaly. Yellow fever causes hematemesis as well as sudden fever, bradycardia, jaundice, and severe prostration.
Two relatively common disorders may cause hematemesis in rare cases. When acute diverticulitis affects the duodenum, GI bleeding and resultant hematemesis occur with abdominal pain and fever. With GI involvement, secondary syphilis can cause hematemesis; more characteristic signs and symptoms include a primary chancre, rash, fever, weight loss, malaise, anorexia, and headache.
PHYSICAL
ASSESSMENT:
Take the patient's vital signs. Take his blood pressure and pulse while he's in a supine, sitting, or standing position.
Inspect the mucous membranes, nasopharynx, and skin for signs of bleeding or other abnormalities.
Palpate the abdomen for tenderness, pain, or masses. Note lymphadenopathy.
Take the patient's vital signs. Take his blood pressure and pulse while he's in a supine, sitting, or standing position.
Inspect the mucous membranes, nasopharynx, and skin for signs of bleeding or other abnormalities.
Palpate the abdomen for tenderness, pain, or masses. Note lymphadenopathy.
SPECIAL
CONSIDERATIONS:
Closely monitor the patient's vital signs, and watch for signs of shock. Check the patient's stools for occult blood, and keep accurate intake and output records.
Closely monitor the patient's vital signs, and watch for signs of shock. Check the patient's stools for occult blood, and keep accurate intake and output records.
PEDIATRIC
POINTERS:
Hematemesis is less common in children than in adults and may be related to foreign-body ingestion.
Occasionally, neonates develop hematemesis after swallowing maternal blood during delivery or breastfeeding from a cracked nipple.
Hemorrhagic disease of the neonate and esophageal erosion may cause hematemesis in infants; such cases require immediate fluid replacement.
Hematemesis is less common in children than in adults and may be related to foreign-body ingestion.
Occasionally, neonates develop hematemesis after swallowing maternal blood during delivery or breastfeeding from a cracked nipple.
Hemorrhagic disease of the neonate and esophageal erosion may cause hematemesis in infants; such cases require immediate fluid replacement.
AGING ISSUES:
In elderly patients, hematemesis may result from a vascular anomaly, an aortoenteric fistula, or upper GI cancer.
Chronic obstructive pulmonary disease, chronic liver or renal failure, and chronic NSAID use all predispose elderly patients to hemorrhage secondary to a coexisting ulcerative disorder.
In elderly patients, hematemesis may result from a vascular anomaly, an aortoenteric fistula, or upper GI cancer.
Chronic obstructive pulmonary disease, chronic liver or renal failure, and chronic NSAID use all predispose elderly patients to hemorrhage secondary to a coexisting ulcerative disorder.
PATIENT
COUNSELING:
Instruct the patient on what to expect from diagnostic testing, which may include complete blood count, endoscopy, and barium swallow.
Instruct the patient on what to expect from diagnostic testing, which may include complete blood count, endoscopy, and barium swallow.
Bibliography:
1. Rapid Assessment, A
Flowchart Guide to Evaluating Signs & Symptoms, Lippincott
Williams & Wilkins, 2004.
2. Professional Guide to
Signs and symptoms, Edition V, Lippincott
Williams & Wilkins, 2007.
3. Guide to common
symptoms, Edition V, McGraw - Hill, 2002.
Dorin,
Merticaru (2010)