HEMATEMESIS is defined as vomiting of blood derived from bleeding anywhere in the upper gastrointestinal (G-I ) tract. The upper G-I tract is made up of the esophagus, stomach, and duodenum ( the first part of the small bowel).
One has to differentiate hematemesis from hemoptysis (coughing up of blood), epistaxis (nose bleed), and bleeding from the mouth and throat.
Blood from the lungs is bright red and mixed with frothy (foamy) or purulent sputum, while blood from the stomach is dark red and mixed with food particles. Inspection of the nose, mouth, or throat will reveal the source of bleeding.
Hematemesis in a baby that occurs 12-24 hours after birth may be due to swallowed maternal blood during delivery. There are tests that can differentiate maternal from baby's blood. Another source of swallowed maternal blood in the newborn is the breast. Cracked nipples may bleed during feeding and the blood is swallowed by the baby.
Majority of the causes of hematemesis are divided into two categories: mucosal abnormalities (70-80 percent) and esophageal varices (10 percent).
Mucosal abnormalities include irritation, inflammation or ulcerations of the mucosal lining of the esophagus, stomach or duodenum.
Inflammation or ulceration related to acid-pepsin secretion of the stomach is commonly called peptic ulcer or peptic ulcer disease.
The causes of ulcerations are classified into: primary and secondary.
Primary cause in majority of cases is related to H.pylori bacteria infection. Secondary causes include: intake of drugs and chemicals (aspirin, cortisone, alcohol); ingestion of strong corrosive substances (strong acid, alkali, iron); foreign bodies (pins, coins, cola cap cover, soda can pull-stab); or from protracted or prolonged vomiting.
In the newborn period, bleeding and/or perforations are the most common presenting symptoms of peptic ulcer disease.
In young children, the symptoms are generalized vague abdominal pains and vomiting, sometimes with blood. In older children and adolescents, the typical "ulcer pain" related to food intake is found only in 30 percent of cases.
The majority will complain of vague abdominal pains or discomfort. Most children have episodes of vomiting and majority will have blood in the vomitus.
Esophageal varices or dilatation of the blood vessels of the esophagus occur in children as a complication of liver disease. The integrity of the dilated blood vessel walls can easily be disrupted leading to rupture and bleeding.
Bright red blood coming out of the mouth without effort and without pain usually indicates bleeding from esophageal varices. This is usually suggested by history of liver problems (jaundice, hepatitis, cirrhosis) and findings of enlarged liver. In patients with abnormal liver functions, bleeding is usually difficult to control.
Parents tend to exaggerate the amount of blood loss. The health care provider should ask the parents to specify the amount of bleeding, whether a drop, a spoonful, a cupful, a glassful or more. Most patients seen in consultation have lost only small amounts of blood, maybe one or two drops or just a blood stained vomitus.
Most of these patients have a known cause of their vomiting and the blood was only the result of irritation. In these cases, the parents and the child should be reassured and the cause of the vomiting treated. On some occasions one will see children with true hematemesis.
These children are more likely to have acute rather than the chronic hematemesis of adults. The child is either vomiting fresh blood or the darker "coffee-ground" looking material. Fresh blood signifies acute or rapid blood loss while "coffee-ground" looking bloody materials means that the blood has had some time being acted upon or denatured by the stomach acid. This is an indication of slower blood loss.
These patients should be admitted to the hospital even if the bleeding has stopped since recurrence of bleeding is common particularly in patients with esophageal varices or peptic ulcer disease. Patients with large amounts of blood loss should be assessed quickly and the necessary emergency management, supportive care, preventive measures, diagnostic evaluation, and treatment should be undertaken without delay. (PVI)
