Hematemesis, defined as vomiting blood, is a striking symptom that can range in appearance from bright red to dark, coffee-ground like emesis. This alarming presentation signifies bleeding originating from the upper gastrointestinal (GI) tract, typically proximal to the ligament of Treitz. While hematemesis itself is a symptom, determining its underlying cause through differential diagnosis is crucial for effective patient management. This article provides a comprehensive overview of the differential diagnosis of hematemesis, essential for healthcare professionals.
Understanding the presentation of hematemesis is the first step in formulating a differential diagnosis. Bright red hematemesis usually indicates a brisk bleed, often from the esophagus or stomach, where the blood has not been significantly altered by gastric acid. Conversely, coffee-ground emesis suggests slower bleeding or blood that has been exposed to gastric acid for a longer duration, causing the hemoglobin to be converted to acid hematin. It’s also important to differentiate true hematemesis from hemoptysis (coughing up blood) and the vomiting of swallowed blood, such as from a nosebleed. Hemoptysis is typically associated with coughing and is bright red and frothy, while a history of epistaxis can usually clarify swallowed blood.
Differential Diagnosis of Hematemesis: Common Causes
The differential diagnosis for hematemesis is broad, encompassing a range of conditions from relatively benign to life-threatening. The most common causes can be categorized and considered systematically:
Peptic Ulcer Disease
Peptic ulcer disease (PUD), encompassing both gastric and duodenal ulcers, stands as the most frequent etiology of upper GI bleeding and hematemesis. These ulcers erode through the mucosal lining and can involve underlying blood vessels, leading to significant hemorrhage. Risk factors include Helicobacter pylori infection, nonsteroidal anti-inflammatory drug (NSAID) use, and smoking. Patients often present with a history of epigastric pain, which may be related to meals, although this classic presentation is not always reliable, especially in bleeding ulcers.
Esophageal Varices
Esophageal varices are dilated submucosal veins in the esophagus, predominantly caused by portal hypertension secondary to liver cirrhosis. These varices are prone to rupture, leading to massive, often painless hematemesis. Risk factors include a known history of liver disease, alcohol abuse, and viral hepatitis. Variceal bleeding is a critical emergency due to the potential for rapid and substantial blood loss.
Gastritis and Erosive Esophagitis
Inflammation of the gastric mucosa (gastritis) and esophagus (esophagitis) can cause erosions in the lining, leading to hematemesis. These conditions can be triggered by various factors, including NSAIDs, alcohol, stress, and reflux of gastric acid into the esophagus (gastroesophageal reflux disease or GERD). The bleeding is typically less severe than from ulcers or varices, but can still be clinically significant.
Mallory-Weiss Tear
A Mallory-Weiss tear is a linear mucosal tear at the gastroesophageal junction, typically caused by forceful retching or vomiting. This condition is often associated with alcohol intoxication but can occur in any situation involving severe vomiting. Mallory-Weiss tears usually present with hematemesis after an episode of vomiting, and the bleeding often stops spontaneously.
Less Common but Significant Causes
While the above conditions represent the majority of hematemesis cases, other less common but important causes must be considered in the differential diagnosis:
Gastric Cancer
Although less frequent than peptic ulcer disease, gastric cancer can present with hematemesis. The bleeding may be chronic and low-grade or, less commonly, acute and severe. Risk factors for gastric cancer include older age, H. pylori infection, smoking, and a diet high in smoked or salted foods. Weight loss, anorexia, and persistent abdominal pain may accompany hematemesis in gastric cancer.
Dieulafoy’s Lesion
Dieulafoy’s lesion, also known as a caliber-persistent artery, is an abnormally large artery in the submucosa of the stomach (most commonly) or duodenum that erodes through the overlying mucosa, causing significant, often painless bleeding. It is a less frequent cause of hematemesis but can be responsible for recurrent upper GI bleeds.
Angiodysplasia
Angiodysplasia refers to small, abnormal blood vessels in the GI tract, which can bleed. While more commonly associated with lower GI bleeding, angiodysplasia in the upper GI tract can cause hematemesis, particularly in older adults.
Aortoenteric Fistula
Aortoenteric fistula is a rare but life-threatening condition involving an abnormal connection between the aorta and the gastrointestinal tract, most commonly the duodenum. It typically occurs as a complication of previous aortic graft surgery but can also arise from aortic aneurysms or erosion from adjacent masses. Aortoenteric fistula often presents with a “herald bleed” – a smaller initial bleed followed by massive, exsanguinating hematemesis. This diagnosis must be considered in patients with a history of aortic surgery presenting with upper GI bleeding.
Diagnostic Approach to Hematemesis
Establishing the differential diagnosis of hematemesis requires a systematic approach:
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History and Physical Examination: A detailed history is paramount. This includes characterizing the hematemesis (color, amount, frequency), associated symptoms (abdominal pain, weight loss, dysphagia), past medical history (liver disease, PUD, prior surgeries), medication history (NSAIDs, anticoagulants), and risk factors (alcohol, smoking). Physical examination should focus on vital signs to assess hemodynamic stability and signs of chronic liver disease, anemia, or malignancy.
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Nasogastric (NG) Aspiration: Insertion of an NG tube and aspiration can confirm upper GI bleeding. Aspirating blood or coffee-ground material supports an upper GI source. However, a clear aspirate does not exclude upper GI bleeding, as bleeding may have ceased, or the source may be distal to the stomach.
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Esophagogastroduodenoscopy (EGD): EGD is the gold standard for diagnosing the cause of upper GI bleeding, including hematemesis. It allows direct visualization of the esophagus, stomach, and duodenum, enabling identification of mucosal lesions, varices, ulcers, and masses. Furthermore, therapeutic interventions, such as band ligation of varices, sclerotherapy, and hemostasis of bleeding ulcers, can be performed during endoscopy.
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Laboratory Investigations: Blood tests, including complete blood count, coagulation studies, liver function tests, and blood type and crossmatch, are essential to assess the severity of bleeding, identify coagulopathies, and prepare for potential blood transfusions.
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Angiography and Radionuclide Scanning: In cases of ongoing, brisk bleeding where EGD is non-diagnostic or technically challenging, angiography or radionuclide bleeding scans may be utilized to localize the bleeding site, particularly in lower GI bleeding or when upper GI source is not confirmed by EGD.
Clinical Significance and Management Implications
Hematemesis is a symptom that necessitates prompt medical evaluation and management. The differential diagnosis guides the subsequent treatment strategy. Initial management focuses on resuscitation and hemodynamic stabilization, including intravenous fluid resuscitation and blood transfusions as needed. Once the patient is stabilized, diagnostic endoscopy is crucial to identify the source of bleeding.
Definitive treatment is directed at the underlying cause. For peptic ulcer bleeding, treatment includes acid suppression with proton pump inhibitors (PPIs) and eradication of H. pylori if present. Variceal bleeding is managed with endoscopic band ligation or sclerotherapy, along with pharmacological therapy to reduce portal pressure. Mallory-Weiss tears typically heal spontaneously, but endoscopic hemostasis may be necessary in persistent bleeding. Gastric cancer requires a multidisciplinary approach, including surgery, chemotherapy, and radiation therapy. Dieulafoy’s lesions and angiodysplasia can often be treated endoscopically. Aortoenteric fistulas require urgent surgical intervention.
Table 85.2: Common Causes of Upper Gastrointestinal Hemorrhage. This table provides a summary of frequent conditions leading to bleeding in the upper GI tract, which are crucial to consider when diagnosing hematemesis.
Table 85.1: The History in Gastrointestinal Bleeding. This table outlines key historical information to gather from patients presenting with gastrointestinal bleeding, aiding in differential diagnosis and risk stratification.
Conclusion
Hematemesis is a significant clinical sign indicating upper gastrointestinal bleeding. A thorough understanding of its differential diagnosis is essential for timely and appropriate management. By systematically considering common and less common causes, utilizing a stepwise diagnostic approach, and directing treatment at the underlying etiology, clinicians can effectively manage patients presenting with hematemesis and improve outcomes.
