Vomiting blood, medically termed hematemesis, originates from bleeding in the upper gastrointestinal (GI) tract, which includes the esophagus, stomach, and the first part of the small intestine (duodenum). Hematemesis is always a serious medical event because the body can lose a significant volume of blood rapidly. Anyone who experiences hematemesis should seek emergency medical attention without delay due to the potential for massive hemorrhage and shock. Understanding the nature of the blood can offer important clues about the source and urgency of the internal bleeding.
Recognizing Severity, Appearance, and Urgency
The appearance of the blood provides immediate insight into the location and activity of the bleeding source. If the vomit is bright red, it indicates fresh, active bleeding, often suggesting the source is in the esophagus or stomach. Since the blood has not been exposed to stomach acid for long, this presentation often signifies a rapid and potentially massive hemorrhage.
If the blood has a dark brown, granular texture, resembling coffee grounds, it suggests the blood has been partially digested by the strong hydrochloric acid in the stomach. This “coffee ground” material usually indicates a slower, less active bleed, or a bleeding source within the stomach or duodenum. However, even this appearance can precede a major bleeding event, and its presence still warrants immediate evaluation.
It is helpful to distinguish hematemesis from hemoptysis, which is coughing up blood that originates from the lungs or respiratory tract. Hematemesis is typically mixed with food particles and stomach contents, while blood from the lungs is often frothy and bright red due to being mixed with air and mucus. Regardless of the appearance, signs of shock, such as dizziness upon standing, a rapid heart rate, or confusion, require an immediate call to emergency services.
Common Causes Related to Mucosal Damage
Peptic Ulcer Disease (PUD) is the most frequent cause of upper GI bleeding, accounting for up to half of all cases. These open sores form on the lining of the stomach (gastric ulcers) or the duodenum (duodenal ulcers). PUD is often caused by infection with the bacterium Helicobacter pylori or long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs).
Acid in the stomach and duodenum erodes the protective mucosal layer, exposing underlying tissue to damage. While most ulcers cause slow, chronic bleeding, the ulcer can deepen over time, eventually eroding into a small artery or vein, which results in a more significant bleed and subsequent vomiting of blood. NSAIDs like ibuprofen or naproxen are damaging because they interfere with the production of prostaglandins, compounds that help maintain the stomach’s mucosal barrier.
A Mallory-Weiss tear is a common cause, defined as a linear laceration in the mucous membrane at the junction of the esophagus and stomach. This tear is caused by a sudden, forceful increase in intra-abdominal pressure, typically from severe or prolonged retching and vomiting. The pressure gradient causes the esophageal lining to tear, leading to a bright red bleed that is often self-limiting but can still cause substantial blood loss.
Inflammation of the lining, known as gastritis (stomach) or esophagitis (esophagus), can also cause bleeding. These conditions are frequently triggered by chronic acid reflux (GERD), excessive alcohol consumption, or the use of certain medications. The inflamed tissue is fragile and can easily weep blood, sometimes sufficient to cause the characteristic coffee ground appearance. Swallowed blood from a severe nosebleed or a bleeding lesion in the mouth or throat is a non-GI cause that may also be vomited back up.
Severe Conditions Involving Major Vascular Bleeding
The most dangerous causes of hematemesis involve the rupture of major blood vessels. Esophageal varices are one such condition, representing greatly enlarged and fragile veins in the lower part of the esophagus. They develop due to portal hypertension, a condition where blood flow through the liver is obstructed, most commonly by cirrhosis or severe liver scarring.
The blocked flow forces blood to find alternative routes through smaller veins in the esophageal lining, causing them to swell. When these thin-walled varices rupture, they release blood under high pressure, resulting in massive, life-threatening bleeding that is typically bright red. This type of hemorrhage has a high mortality rate and requires immediate, specialized medical intervention.
A deep peptic ulcer that has eroded completely through the GI wall into a major artery is another severe but less common cause. While most ulcers involve smaller vessels, ulcers located on the posterior wall of the duodenum are particularly dangerous as they lie close to the gastroduodenal artery. Erosion into this artery can lead to a massive arterial bleed, which is extremely difficult to control and requires urgent intervention to prevent hemorrhagic shock.
A rare but almost universally fatal condition is an aortoenteric fistula, an abnormal connection formed between the aorta and the GI tract, most often the duodenum. This is usually seen in patients who have previously had surgery to repair an abdominal aortic aneurysm, where the synthetic graft erodes into the bowel. The bleeding starts as a small “herald” bleed, but this connection inevitably opens, leading to a massive hemorrhage that requires emergency vascular surgery. Bleeding from advanced gastric or esophageal cancer occurs when the tumor erodes into surrounding blood vessels as it grows.
Medical Diagnosis and Intervention
When a patient arrives with hematemesis, the initial priority is rapid assessment of hemodynamic stability and immediate resuscitation. Establishing large-bore intravenous access is done quickly to allow for the rapid infusion of crystalloid fluids and blood products to restore blood volume and blood pressure. Blood tests, including a complete blood count and coagulation studies, are ordered to determine the severity of blood loss and the patient’s clotting ability.
The primary diagnostic and therapeutic procedure is an upper endoscopy (EGD). During this procedure, a flexible tube equipped with a camera is passed down the esophagus to visualize the upper GI tract and locate the precise source of bleeding. For most patients, this examination is performed within 24 hours of presentation, but it is done urgently if the patient is unstable or the bleeding is massive.
Once the bleeding source is identified, the endoscopist delivers specific interventional treatments directly to the site. For non-variceal bleeding, such as from an ulcer, this involves combination therapy, typically injecting a vasoconstrictor like dilute epinephrine into the area to cause temporary compression. This is followed by a secondary treatment, such as thermal coagulation (using heat to cauterize the vessel) or the application of metal hemoclips to mechanically close the vessel.
If the bleeding is from ruptured esophageal varices, the treatment of choice is endoscopic band ligation (EBL). This technique involves placing tiny elastic bands around the base of the enlarged veins to strangulate them, stopping the blood flow and causing the varix to slough off. Patients with suspected variceal bleeding are also treated with vasoactive medications to reduce the pressure in the portal vein system, as well as prophylactic antibiotics to prevent infection due to their underlying liver disease.