Vomiting blood

Hematemesis or vomiting blood is a very serious symptom that means there is bleeding in the esophagus, stomach or duodenum, that is, the upper gastrointestinal tract. Such vomiting can be with stomach contents (as blood) or with blood only (bright red or darker).

Causes of the bloody vomit

The most common causes of this symptom are related to GI problems and include:

• esophageal diseases, primarily erosive and hemorrhagic esophagitis, and peptic esophageal ulcer; [1]
• causing esophageal erosion [2] acid backflow from the stomach cavity into the esophagus in severe gastroesophageal reflux disease (GERD); [3], [4]
• Chronic reflux gastritis; [5], [6]
• bleeding stomach and duodenal ulcer. [7], [8], [9]

As a consequence of liver cirrhosis, portal hypertension, i.e. Increased pressure in the portal vein (the vein of the portal system of the liver), [10] can lead to esophageal and gastric varices with thinning of their vascular walls - causing their rupture and vomiting of blood. [11]

Sudden vomiting of blood and abdominal pain (in the epigastric region) are symptoms not only of an exacerbation of peptic ulcer disease and pancreatitis (acute or chronic inflammation of the pancreas), [12] but also intestinal amyloidosis. [13]

Excessive alcohol consumption leads to irritation of the pharyngeal mucosa with ulceration and bleeding, and in the presence of gastritis - with damage to the gastric mucosa, so vomiting blood after alcohol may occur. In this case, there may be a non-skid rupture of the mucosa of the gastroesophageal junction (complex gastroesophageal valve), called Mallory-Weiss syndrome, which is provoked by frequent gagging or severe vomiting with chronic alcohol abuse. [14], [15]

There may also be vomiting with blood in poisoning with nitric acid, arsenic and its compounds, mercury, formaldehyde, etc. Other symptoms, such as in nitric acid poisoning, are throat swelling, difficulty breathing, rapid drop in blood pressure.

Vomiting scarlet blood occurs in gastrointestinal bleeding, which gastroenterologists associate with significant mucosal erosion or peptic ulcer disease of the stomach and duodenum. [16], [17]

As a rule, vomiting bile with blood is the result of the presence of concrements (stones) in the gallbladder, i.e. Gallstone disease. In addition, bile stagnation with such symptoms is possible in patients with liver or pancreatic diseases.

And fever and vomiting blood are typical of viral hemorrhagic fevers [18] and are often seen in helminthic diseases: intestinal strongyloidosis (caused by the intestinal eelgrass nematode Strongyloides stercoralis) [19] and hepatic or intestinal schistosomiasis (developing when infected with the parasite Schistosoma mansoni). [20], [21]

Among the etiologic factors of vomiting with blood also stand out:

• nosebleed with blood in the throat and stomach;
• long-term use of non-steroidal anti-inflammatory drugs (NSAIDs), as well as bisphosphonates used to treat osteoporosis;
• Performing medical procedures with accidental trauma to the stomach or esophagus;
• exposure to high doses of radiation;
• Malignant tumors of the stomach, esophagus, or pharynx.

Vomiting blood in a baby

In children, hematemesis may be a manifestation:

• esophageal foreign bodies;
• hemorrhagic disease of the newborn, manifested a few days after birth (along with black color of feces - melena and the presence of blood in the urine - hematuria); [22]
• Dielafois vascular malformation, a large tortuous artery in the submucosa of the stomach wall (which collapses and bleeds with recurrent vomiting of blood and melena);
• congenital hemorrhagic telangiectasia (Osler-Weber-Rendue disease), a rare inherited disease that results in the abnormal formation of blood vessels in the skin, mucous membranes and organs of the digestive tract; [23]
• ulcerative gastric tumor or hereditary diffuse gastric cancer; [24]
• of intra-abdominal non-Hodgkin's lymphoma. [25]

Vomiting blood in pregnancy

Nausea and vomiting in toxicosis in early pregnancy is a common phenomenon, which due to the dramatic change in hormonal background is noted in 75-85% of all pregnant women. Although in most women these symptoms are limited to the first trimester, some women experience them for much longer. And women with severe nausea and vomiting - due to constant irritation of the mucosa of the esophagus and the back of the pharynx - may experience vomiting with blood during pregnancy. [26]

But in the simplest case, hematemesis is due to swelling, soreness, hypersensitivity and bleeding of the gums during pregnancy (because pregnant women have an increased volume of circulating blood). Also, pressure on the walls of intranasal blood vessels increases in pregnancy - with an increased likelihood of nosebleeds.

Pathogenesis

In the medulla oblongata is the vomiting center, which controls the act of vomiting; it is this center that initiates a series of contractions of the smooth muscles lining the digestive tract.

The gag reflex is mediated by the main visceral sensory nucleus of the brain, the nucleus of the solitary tract (NTS), which controls the gastrointestinal tract via the IX and X pair of cranial nerves: the lingual (n. Glossopharyngeus) and vagus (n. Vagus) nerves.

The main provoking factor in the pathogenesis of bleeding from the upper GI tract - inflammation and damage to the mucous membrane of the stomach and duodenum when the balance of gastric acid secretion and protection of the mucosa from its effects.

As the ulceration spreads into the submucosal layer (permeated by blood vessels), the cells of the vascular wall tissues weaken and die, resulting in damage and subsequent hemorrhage.

For the mechanism of hematemesis in peptic ulcer disease, see the publication - Bleeding from gastric and 12 peptic ulcers

The pathogenesis of vomiting is due to the effect of neurotransmitters (glutamic acid, acetylcholine, noradrenaline, serotonin) on afferent fiber neurons of the vagus nerve, which leads to activation of efferent fibers of the vagus and laryngeal nerves, which conduct signals to the upper GI tract. In the lower parts of the digestive tract, impulses pass through the vagus and sympathetic nerves, and through the spinal nerves (diaphragmatic and thoracoabdominal) to the diaphragm and abdominal muscles (anterior abdominal wall), causing their contraction.

First, the muscles of the stomach wall relax, followed by retrograde peristalsis of the small intestine (of which the duodenum is a part). The second phase begins with respiratory arrest in mid-inspiration; then the hyoid muscle and larynx are raised, opening the upper esophageal sphincter (between the pharynx and esophagus); at the same time - due to stimulation of the internal branch of the upper laryngeal nerve (n. Laryngeus superior) - vocalization of the upper esophageal sphincter. Laryngeus superior) - the vocal cleft of the larynx reflexively closes, and the soft palate due to contraction of the levator veli palatini muscle (innervated by the recurrent laryngeal nerve) rises and closes the nasopharynx.

And then diaphragmatic, external intercostal and abdominal motor neurons are activated, providing contraction of the diaphragm, inspiratory intercostal muscles and muscles of the anterior abdominal wall, which leads to an increase in intra-abdominal pressure and upward movement of gastric contents with its ejection.

Diagnostics of the bloody vomit

The history and information regarding the timing, frequency, volume and nature of vomiting, as well as associated symptoms (dyspepsia, epigastric pain, dysphagia, melena, weight loss, etc.) are important for the diagnosis of vomiting blood.

Instrumental diagnostics, including X-ray of the esophagus and stomach; endoscopic examination of the esophagus, stomach and duodenum; ultrasound of the gastrointestinal tract, abdominal ultrasound.

For laboratory tests are taken: general blood count, complex metabolic panel (biochemical blood test), coagulogram (blood coagulation test), coprogram (stool analysis), stool analysis for hidden blood.

The differential diagnosis of vomiting with blood is designed to establish its cause.

Also read:

• Diagnosis of peptic ulcer disease

Diagnosis of chronic esophagitis

• Diagnosis of gastric cancer
• Portal hypertension - Diagnosis
• Intestinal Amyloidosis - Diagnosis

Treatment of the bloody vomit

Patients with vomiting blood who are hemodynamically unstable may require urgent transfusion of blood or fresh frozen plasma and administration of Octreotide or Terlipressin (Remestip) to reduce visceral blood flow.

Treatment for peptic ulcer disease consists of adrenaline injections and electrocoagulation of bleeding vessels during gastroscopy, followed by intravenous administration of drugs from the group of proton pump inhibitors to reduce gastric acid secretion.

Treatment options depend on the suspected or confirmed underlying causes:

• Gastroesophageal reflux disease (GERD) - Treatment
• Treatment of gastric and duodenal ulcers
• Chronic pancreatitis: drug and surgical treatment
• Esophageal foreign bodies - Treatment
• Schistosomiasis - Treatment and Prevention
• Gastric cancer treatment

Active bleeding from esophageal varices requires endoscopic sclerotherapy, and in case of persistent portal hypertension, surgical treatment consists in creating a bypass communication pathway between the incoming portal vein and the outgoing hepatic vein by transjugular intrahepatic portosystemic shunt.

According to experts, surgery is usually resorted to if the source of bleeding cannot be identified endoscopically and a laparotomy is necessary.

Complications and consequences

Possible complications of vomiting blood include dehydration with electrolyte imbalance, acute posthemorrhagic anemia, and severe blood loss, where a decrease in arterial blood volume creates a risk of hypovolemic shock. For more information see. - Hypovolemia