If one wants to get to the bottom of it, it requires big gun diagnostic tests to confirm the source.
One of the bedside diagnostic questions is whether the patient is vomiting bright red blood or whether what comes out looks more like black sand/coffee grounds.
The distinction may help to guess the problem or source.
Bright red blood usually indicates that the source of the bleeding is more proximal (closer to the mouth) in the GI system - such as a tear in the esophagus or a bleeding gastric ulcer. Copious bright red blood can also be a bad sign that the bleeding is really fast and extreme wherever the source because it's flowing fast enough that it doesn't have time to coagulate.
The vomit that looks more like coffee grounds tends to be more distal (closer to the anus) and/or a slower bleed because it has time to change form. This could be something like a duodenal ulcer passed the pyloric sphincter after the stomach.
Evaluation and treatment of an upper GI bleed has two phases:
1) assessing the degree of blood loss and replacing losses if necessary.
This mostly involves a blood test to check the hemoglobin count to see if it's low enough to require a transfusion. Basic labs like checking liver, bile duct and pancreatic enzymes can also be run, but rarely indicate the source.
If the patient is still actively vomiting, they can also be given IV fluids, electrolytes and antiemetic drugs to slow nausea.
2) Assessing the source of the upper GI bleed
This part is much messier. Essentially there aren't sufficient tools in the ER to do this.
X-rays and ultrasounds are mostly useless. A CT scan, which is a big test available in most ERs, may in theory identify the source of the bleed but often can't because it's still looking externally for an internal bleeding problem.
The test that is most required is an upper GI gastroscopy, the garden house down the throat to actually check the inside of the pipes to find the bleed. Awful test and hard to get down, particularly in the setting of an emergency.
Potential causes of an upper GI bleed/hematemesis
- esophageal tear
- bleeding peptic ulcer
- duodenal ulcer
- esophageal varices from alcoholism
- Crohn's disease (more likely to involve the bottom half)
- general bleeding disorder (usually other bleeding sites - nose bleeds, skin bruising, rectal bleeding)
- upper GI cancers (most prevalent with advancing age, smokers, drinkers, family history, etc)
If the vomiting blood has stopped and stabilized and no longer requires emergency care:
- next steps really depend on age and risk factors of the patient
- anybody 50+ or with significant risk factors (smoking, drinking, already on long-term anticoagulation, family history of upper GI cancers, known stomach ulcers, long history of acid reflux, liver disease, history of bulimia) should seek outpatient consultation with a family doc, nurse practitioner or walk-in clinic
- as an outpatient, two main things are needed, A) a blood test to check hemoglobin and iron levels to evaluate blood losses and potential need for iron replacement and B) a referral to a surgeon or gastroenterologist for an upper Gi scope to look for causes
- a younger person under 40 with no risk factors and no prior history of upper GI problems may be able to get away with no further evaluation if the problem stops. Though a blood test for hemoglobin to assess amount of blood loss still wouldn't hurt,
If one doesn't have easy access to medical care or long waits, things to be done in interim
- stop anticoagulants like baby aspirin if one thinks it's safe (ie. If it's solely for prevention and not for an active heart or clotting condition, history of DVTs, etc). Best to consult with a doc first if able
- stop taking any OTC painkillers except Tylenol/acetaminophen. Avoid aspirin/ASA/Advil/ibuprofen/naproxen/Aleve. These are all causes of ulcers and stomach bleeding.
- avoid all alcohol, unless already an alcoholic and need supervised detox. Alcohol is a major contributor to GI bleeding and liver disease.
- consider taking an OTC PPI (Proton Pump Inhibitor) acid reflux drug daily if able or not already on one. Not sure about availability in Canada but freely available in the US. Such names include Prevacid/Nexium/Pantoloc (lansoprazole/omeprazole/esomeprazole/pantoprazole, etc). This may help to heal ulcers and avoid further bleeding in the interim. Unfortunately other acid reflux drugs aren't a substitute (Zantac/ranitidine, Tums, Pepcid AC, Pepto, etc).
- reducing smoking and vaping in the interim. Pretty much all causes of upper GI bleeds are worsened by nicotine.
