Bloody Vomit

Our anxiometer needle moves a little higher when patients arrive in ERs spewing blood, but the buzz words are virtually the same as they are for lower GI bleeding.

Red Flags:

• Lightheaded
• Syncope
• Abdominal pain
• Fevers
• Concurrent bloody stool
• Taking blood thinners like warfarin, Xarelto or Plavix
• Underlying anemia
• Hemophilia
• Liver failure
• Dialysis
• Elderly
• Smoker
• Prior need for transfusions
• Known esophageal or stomach cancer
• Known ulcers or H. pylori
• Alcoholism / cirrhosis / hepatitis
• Esophageal varices
• Chronic NSAID use (ibuprofen, naproxen, aspirin)
• Chronic steroid use
• Recent GI or neck surgery, especially around carotids or aorta
• Community outbreak of infectious gastroenteritis

Happy Words

• “Pretty sure I ate something bad at a party yesterday. I puked up food all night, and then noticed some red streaks.”
• “Vomiting has stopped and no more pain.”
• “I’m otherwise healthy and taking sips of Gatorade now.”
• “Lots of guys in my frat vomited after that pasta. It’s either blood or sauce.”
• “I had a nose bleed all day yesterday. It finally stopped today.”
• “I just had a tonsillectomy and can taste blood oozing down.”

Despite the dramatic and sometimes startling appearance, most folks who throw up a little blood get better with nothing more than hydration +/- Zofran to control the nausea. Wounds inside the nose, pharynx, esophagus and stomach are prone to heal just like wounds to our skin. Unlike external skin bleeding, however, direct pressure to limit internal GI bleeding isn’t as easy. Plus there are some bleeding sites like esophageal varices, which are like ticking bombs.

We do the same studies that we might for lower GI bleeding, which include tests for anemia, and tests for liver and coagulation problems. If you put on a good enough show, you may be offered a nasogastric tube, or “NG.” This can be both diagnostic and therapeutic, because it tells us how much you may be bleeding while helping relieve some nausea associated with a distended stomach. However, insertion is not fun.

A rectal exam is useful to determine degree of bleeding as well. If no blood we feel comforted. If trace dark bloody stool, we suspect an upper GI source. If bright red blood from below combined with active bleeding through the NG, then we call in the cavalry.

A “urease breathe test” may help to determine if H.pylori is the cause of bleeding and discomfort, though this is largely an outpatient study.

Zofran and phenergan are popular to slow nausea and vomiting. Less vomiting also means less tearing and bleeding as well. OTC Zantac and Pepcid may prove helpful if you can keep pills down just to limit acid production in the short term. Prilosec and other “PPIs” help for long term stomach acid reduction. Addition of antibiotics for H.pylori has probably been the single most important reducer of bleeding ulcers in the past couple decades.

A chat with your PCP or Pre-R may be helpful to determine best next steps, but the ER really is the best place for stabilization and possible transfusion if you seem to be heading south quickly. That said, a GI doctor is your best bet to diagnose and solve the problem definitively.

Lastly, perhaps more important than anything here is to mention problems caused by NSAIDs. Most of you know not to drink to excess or inject heroin, in part to avoid hepatitis, liver failure, varices and vomiting till you bleed to death. However, while ibuprofen is one of my best friends, it too can wreak GI havoc. Therefore, always always take with food… and preferably not high Scoville scale green chile.

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