A client with a history of gastrointestinal varices develops severe hematemesis

The patient with haematemesis and/or melaena

Haematemesis and melaena are common causes of presentation to the emergency department. The term ‘haematemesis’ describes the vomiting of blood, which may be bright red and fresh or altered (commonly described as ‘coffee grounds’). The presence of haematemesis usually means acute bleeding from a source above the duodenojejunal flexure. ‘Melaena’ is faeces containing digested blood; they have a black (often described as ‘jet black’) tarry appearance and a characteristic and offensive smell. Although its presence may suggest acute bleeding from any source proximal to the ascending colon, the most common source is in the upper gastrointestinal tract (Table 9.20).

The passing of fresh blood per rectum (as opposed to melaena) usually means that the source of bleeding is in the large or small bowel. However, it is possible for very rapid upper gastrointestinal bleeding to lead to fresh blood per rectum as there is insufficient time for melaena to develop. Patients who incidentally describe dark stools without the characteristic appearance and smell of melaena do not usually have gastrointestinal bleeding. Iron-stained stool is black but usually solid and formed.

The history should enquire about epistaxis, alcohol intake, pre-existing liver disease and both prescription and over-the-counter drugs. One severe or several episodes of vomiting before the onset of haematemesis may suggest a Mallory-Weiss tear. Epigastric pain may suggest peptic ulcer disease, and unexplained weight loss and anorexia is suggestive of malignancy.

The initial examination should focus on identifying if the patient is in shock and acting accordingly (see above). Young, otherwise fit hypovolaemic individuals may compensate with raised cardiac output and remain normotensive for some considerable time but exhibit a fall in blood pressure on sitting or standing up. Features of malignancy (cachexia, supraclavicular lymphadenopathy, abdominal mass) and chronic liver disease (spider naevi, palmar erythema, jaundice, splenomegaly, ascites) should be noted. The clinical features of anaemia could suggest that there has been a period of occult bleeding before the acute bleed. Rectal examination is mandatory to see if there is objective evidence of melaena or fresh blood.

The initial investigations should include full blood count, clotting screen, urea, electrolytes and liver function tests. Blood should be ‘grouped and saved’, unless the patient is in shock, in which case, for example, four units of blood should be ‘cross-matched’ immediately. Blood is the best replacement fluid for a patient in shock with gastrointestinal bleeding but should not necessarily be given immediately for the stable patient who is anaemic. The availability of urgent upper gastrointestinal endoscopy varies widely among hospitals and different healthcare systems. Whatever the local provision, it follows, rather than replaces, prompt and effective resuscitation in the patient in shock.

Haematemesis

Haematemesis (blood in the vomit) typically results from blood regurgitation from the gastrointestinal tract (mouth, pharynx, oesophagus, stomach and small intestine). Conditions that cause haematemesis include bleeding ulcer(s), neoplasms, angiomas or varices in the stomach, duodenum or oesophagus; prolonged and vigorous retching, which may tear small blood vessels of the throat or oesophagus; drugs; and ingested blood (e.g. swallowed after a nosebleed) or gastroenteritis. It may be difficult to distinguish haematemesis from coughing up blood from the lung (haemoptysis) or a nosebleed (bloody postnasal drainage), but it can also cause blood in the stool.

Associated signs

Hematemesis does not localize the diagnosis to the stomach or GI tract. Because a variety of metabolic and coagulation disorders may result in severe hematemesis, a wide spectrum of physical signs may also be present in affected animals. In addition, blood emanating from the upper respiratory tract may be swallowed and subsequently vomited, giving the appearance that bleeding is from the stomach.

Anorexia and vomiting are the most common associated, but nonspecific, signs. Weight loss, weakness, dark stool (melena), dehydration, and inactivity are other related signs having low diagnostic yield. Severe anemia can result from sustained gastric hemorrhage and if acute may justify exploratory laparotomy to identify the source of the bleeding.

Increased water consumption and urination may suggest underlying renal or hepatic disease. Intracutaneous or subcutaneous tumors, specifically mast cell tumors, can be associated with severe gastric ulceration and bleeding. Ulcerative lesions in the mouth may indicate recent ingestion of caustic or toxic compounds. The frenulum in the mouth should always be examined to rule out linear foreign bodies.

1 What are the signs and symptoms of upper gastrointestinal (UGI) bleeding?

Hematemesis can vary from material that looks like coffee grounds (blood darkened from acid exposure) to massive amounts of bright red blood. Melena (black, tarry stool) is usually found in patients with an upper source, but it may be seen in patients with a right colon bleed and slow transit. Brisker UGI bleeding will result in maroon to red blood. It is likely that the source of bleeding is not from the UGI tract if it is bright red per rectum and not associated with orthostatic blood pressure changes or syncope.

Hematemesis

Hematemesis is the vomiting of blood; it suggests GI ulceration/erosion, coagulopathy, or ingestion of blood. The vomitus may contain bright-red blood or digested blood that resembles coffee grounds. Administration of nonsteroidal anti-inflammatory drugs (especially concurrently with corticosteroids) is a major reason for canine ulceration. Hepatic failure, mast cell tumor, shock, submaximal exertion, and dexamethasone administration must also be considered. After these have been ruled out, endoscopy is indicated and allows diagnosis of ulceration (especially because of a foreign object, inflammatory disease, or neoplasia). Depending upon the particulars of the case, one may perform endoscopy or treat symptomatically.

2 What are hematemesis, coffee-ground emesis, hematochezia, and melena? Are these features helpful in determining the site and rate of bleeding?

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Hematemesis is vomiting of fresh, red blood and indicates bleeding in the upper GI tract. Approximately 50% of patients with upper GI bleeding (UGIB) will present with hematemesis.

If the blood is older, it can appear like coffee grounds. The return of bright red blood or coffee grounds through a nasogastric tube (NGT) is highly specific for hemorrhage proximal to the ligament of Treitz.

Hematochezia is used to describe passage of bright red or maroon-colored blood through the rectum and typically indicates a lower tract source. Less commonly (< 15%) it may indicate the rapid transit of torrential hemorrhage from the upper tract.

Melena is the passage of black, tarry, and usually foul-smelling stool because of degradation of blood components as they traverse the GI tract. It typically signifies upper GI tract bleeding (70%) or, less often, hemorrhage from the proximal lower tract (30%).

Combinations

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Haematemesis, epistaxis, haematuria → Cirsii japonici herba seu radix (da ji), Imperatae rhizoma (bai mao gen) p. 158

Heavy menstrual bleeding → Paeoniae radix lactiflora (bai shao) p. 776

Bleeding of all kinds, unstoppable bleeding → Agrimoniae herba (xian he cao) p. 584, Typhae pollen (pu huang) p. 616, Nelumbinis nodus rhizomatis (ou jie) p. 596, Rehmanniae radix (sheng di huang) p. 168

Strong uterine bleeding → Typhae pollen (pu huang) p. 616

Bleeding due to cold deficiency → Artemisiae argyi folium (ai ye) p. 586, Zingiberis rhizoma (gan jiang) p. 408

Chronic cough with heat → Jujubae fructus (da zao) p. 718

Gastrointestinal bleeding

Hepatic Schistosomiasis

The patient develops hematemesis from esophageal or gastric varices or very rarely from ectopic varices. The hematemesis is usually of sudden onset without prodromal symptoms, rarely it is preceded by dizziness, fatigability, and epigastric discomfort. Melaena can be the first presentation but usually follows hematemesis. The patient is pale, tachycardic, and hypotensive. The liver is shrunken, left lobe may be enlarged, the spleen is usually palpable but after severe bleeding becomes palpable only after resuscitation. Ascites is very rare unless the bleeding is massive due to hepatocellular ischemia. Jaundice and features of chronic liver disease or hepatic encephalopathy are rare, as the hepatocytes are normal in these patients. If there are signs of hepatic decompensation, one should suspect coinfection with hepatitis viruses B or C. Some patients may present with symptoms of anemia due to chronic blood loss from varices, portal hypertension gastropathy, or hypersplenism. Dragging left hypochondrial pain from gross splenomegaly is reported by some patients. Hepatorenal syndrome and spontaneous bacterial peritonitis are rarely seen in pure schistosomiasis.

The differential diagnosis includes visceral leishmaniasis, tropical splenomegaly syndrome, blood disorders, and liver cirrhosis.

Exsanguination

Massive hemoptysis, hematemesis, hematochezia, or exsanguination from a tumor eroding into a major vessel is rare but can be horrifying for professional caregivers, family members, or friends to observe. If the patient is likely to experience such a complication, ensure that dark-colored sheets, towels, and blankets are available to mask the blood. Consider insertion of a peripherally inserted central catheter line in patients who have no indwelling venous access device to ensure intravenous access for patient sedation in the event of a catastrophic terminal event. Appropriate medications should be on hand, either on the hospital unit or in the home. If the patient is enrolled in a hospice program, the nurse can provide instruction for administering prefilled syringes of morphine, to be given intravenously when possible, or a benzodiazepine. Midazolam (Versed) can be given intramuscularly or intravenously; diazepam or lorazepam (e.g., Ativan) can be given rectally. When the event occurs, the patient is placed bleeding side down, in the Trendelenburg position if possible, and given benzodiazepines for anxiety and opioids if dyspnea or pain is present.