What is hematemesis?
Hematemesis is defined as blood in vomiting or vomiting of blood. It indicates that a site or lesion of bleeding is proximal to the duodenal-jejunal junction. Because blood entering into the gut distal to this lesion very occasionally returns to the stomach.
Color of the blood in hematemesis:
Blood color depends on how much time it remained in the stomach. When hemorrhage is rapid and sizable, there may be vomiting of a large volume of bright red blood.
But if bleeding is smaller than the dark blood like coffee grounds color is vomited. This change is due to contact with gastric acid.
What is melena?
Melena in medical terms referred to as the appearance of the character of a black, tarry stool. It occurs when the loss of blood is more than 60 ml from the upper gastrointestinal tract.
The lesion is mostly present in the esophagus, stomach, and duodenum. But rarely hemorrhage into smallest intestine and right side colon may also cause it if GI transit is slow. But if GI movement is fast, there may be also passage of dark red stool from massive upper gastrointestinal bleeding.
Causes of hematemesis and melena
- Esophageal varices
- Mallory-Weiss tear – it is a tear of lower esophageal tissue mostly due to severe forceful vomiting or coughing
- Esophageal carcinoma
- Reflux esophagitis
- Foreign body
- Peptic ulcer
- Erosions or gastritis
- Portal hypertensive gastropathy
- Gastric cancer
- Dieulafoy’s erosion – It is the rupture of the ectatic submucosal artery mostly in the stomach.
Duodenal and jejunal causes:
- Peptic ulcer
- Erosions or duodenitis
- Vascular malformation
- Polyps including Peutz-Jegher’s syndrome
- Aorto-enteric fistula
Following are the causes of Massive upper GI bleeding:
- Esophageal or gastric varices
- Gastric ulcer
- Duodenal ulcer
- Stress ulceration
- Dieulafoy’s erosion
- Aorto-enteric fistula
What are the complications of hematemesis?
Excessive bleeding may cause a fall of blood pressure and sock. If a patient with hematemesis has symptoms like giddiness on postural change, increased respiration rate, pale and cold skin, and reduced urine output, then immediately consult your doctor for emergency care
Anemia is another complication. It usually occurs in unnoticed blood loss and sudden down in Hemoglobin in much hematemesis also.
Rare complication includes aspiration of vomited blood or gastric content. It can be life-threatening. This complication have a higher risk side for those who are elders, alcohol overuse, patient with stroke, and difficulty in swallowing.
How to evaluate cases of hematemesis and melena?
Features in history taking:
- Vomiting and nausea – it is characteristically present in Mallory-Weiss syndrome.
- Heartburn and regurgitation – it is present in reflux esophagitis.
- Dysphagia and weight loss are characteristic symptoms of esophageal malignancy.
- History of peptic ulcers and abdominal pain is also very helpful. Many times bleeding can be the first manifestation of an asymptomatic peptic ulcer.
- Frequent use of drugs like Aspirin or NSAIDs
- Also, ask for alcohol intake and evaluate for chronic liver disease
- A history of easy bleeding or bruising indicates coagulation or platelet disorder.
Examination of the patient:
- Rapid assessment of the hemodynamic state of the patient like…
Does the patient look shocked or pale?
Measure blood pressure and pulse.
Watch for postural hypotension.
- Presence of purpura or petechiae – Widened blood vessels present in Telangiectasia of Rendu-Osler-Weber syndrome. Palpable purpura is characteristic of systemic vasculitis, and perioral pigmentation of Peutz-Jegher’s syndrome. But it is an uncommon cause
- Splenomegaly, ascites or dilated abdominal veins indicate portal hypertension when the patient bleeds from gastric or esophageal varices. In portal hypertensive gastropathy, there may be congested gastric mucosa and this can also be a site for gastrointestinal bleeding in a patient with liver disease.
- In the case of hemobilia triad of biliary colic, jaundice, and melena is present.
Hemoglobin concentration – Blood volume loss is a poor indicator in the first few hours of bleeding because dilution by extracellular fluid recruited into the intravascular space may continue for more than 24 hours. Low hemoglobin level usually signifies chronic blood loss.
Urea and electrolytes – Increased blood urea indicates severe bleeding.
Liver function test – to evaluate liver health.
Prothrombin test – to evaluate coagulation-related health.
It is a very diagnostic and treatment-related method. But in a few patients, it does not define the cause of bleeding due to blood in the lumen preventing proper inspection of the mucosa. In these cases, endoscopy can be repeated. If there is still no diagnosis confirmed and bleeding continues then also go for…
Labeled RBC scan – It can detect rates of blood loss as low as 0.1 ml/minute.
Angiography – It doesn’t detect bleeding at rates below 1 ml/minute. But sometimes reveals underlying vascular abnormalities. But when bleeding is intermittent, both investigations may fail to localize the site of hemorrhage.
Such as CT scan, MRI, x-ray, and ultrasounds may also be done to evaluate the different disorders.
Management and treatment
According to availability before hospitalization health experts can do primary care such as intravenous access with normal saline infusion, oxygen supply, early hospitalization as much as possible in cases of massive bleeding.
In massive hemorrhage and conditions like shock, insertion of large-bore cannula into a substantial vein.
If the pulse rate is more than 100 per minute and systolic blood pressure falls below 100 mmHg, infusion of crystalloids like normal saline should be started.
If blood transfusion is required in 2-4 units of whole cross-matched blood should be given. The aim is to maintain hemoglobin concentration at an adequate level.
Endoscopy should be done within 24 hours and is necessary for
Diagnosis – to plan treatment.
Prognosis – endoscopic findings are helpful to define the further risk of bleeding.
Treatment – to do pharmacological, endoscopic, radiological, and surgical treatment
Fresh frozen plasma or platelet transfusion may also be required to correct coagulopathy or thrombocytopenia in cases of liver disease and other disorders
What are procedures to stop bleeding in hematemesis?
Stopping non-variceal hemorrhage:
Medicines – Various Proton pump inhibitors (PPIs) like omeprazole or pantoprazole is used intravenously to reduce the risk of bleeding and the need for surgical intervention
Medicines for eradication of H pylori.
Endoscopic treatment – injection of adrenaline (1:10000) or alcohol plus thermal method (heater probe) can be used.
Indications for surgery for peptic ulcer bleeding
- Active and profuse bleeding which is unresponsive and preventing endoscopic visualization and treatment and bleeding continues despite the application of endoscopic treatment.
- Endoscopic findings suggestive of rebleeding despite technically successful endoscopic treatment.
- Patient at low-risk death after two unsuccessful attempts at endoscopic treatment.
- High-risk patients, after one failure of endoscopic treatment.
Stopping variceal hemorrhage
Different vasoactive medicines such as vasopressin, glypressin, octreotide, somatostatin, glyceryltrinitrate, terlipressin can be helpful. The doses of the medicine will be decided by the treating doctor.
Modified Sengstaken Blackmore (Minessota) tube insertion in the stomach to stop bleeding. But it is a temporary measure.
Propranolol is used up to a dose that can reduce pulse rate by 20% to reduce the risk of rebleeding.
Injection of sclerotherapy – In this intravariceal injection of sclerosant (5% ethanolamine, 1% polidocanol) can be given. Some of the complications of this treatment may include esophageal ulceration, fever, pleural effusion, pericarditis.
Injection of fibrin glue may also be given.
One of the effective measurement is esophageal band ligation. Banding obliterates varices more efficiently and also has fewer complications. But it may be more difficult to perform in a patient with active bleeding.
What is surgical treatment to stop active variceal hemorrhage?
One surgery is esophageal transection with devascularization and portocaval shunt. But it has a high mortality rate.
Another is TIPS means Transjugular Intrahepatic Portosystemic Shunt. Both the surgery can precipitate encephalopathy.
Hematemesis and Melena FAQs
What is hematemesis ICD 10?
ICD means International Classification of the Diseases and ICD-10 is its 10th version. In this, the diagnosis code for hematemesis is K92.0 (Billable). It became effective on 1st October 2020 in the 2021 edition of ICD-10-CM.
What is melena ICD 10?
K92 is the code for other diseases of the digestive system in ICD 10. In this K92.1 is the diagnostic code for melena and K92.2 is the code for unspecified gastrointestinal hemorrhage.
How long does melena last?
Melena that is black, tarry stool may last for more than a week. But it depends on many factors such as motility of the gastrointestinal tract, amount of blood loss, unnoticed or asymptomatic blood loss, etc.
What is difference between melena and hematochezia?
When there is bleeding in your gastrointestinal tract it appears is melena or hematochezia during passing stool.
In melena, there is black colored, tarry stool. It represents the bleeding from the upper GI tract, usually from the stomach and esophagus. When blood travels from the stomach to the anus through the whole long digestive tract, it becomes black due to oxidation. So it appears as black colored.
While hematochezia is referred to as fresh, red blood with stool. It usually indicates bleeding from the colon, rectum, and anus. The most common causes of hematochezia are hemorrhoids, colon cancer, diverticulitis, polyps, benign tumor, etc.
This article is for information purposes only and is not a substitute for legal advice, diagnosis, treatment, etc. If you have any kind of symptoms or problems in the body, please consult your doctor before taking any action. Thank you. Have a nice day.