Hematemesis

DEFINITION & PATHOPHYSIOLOGY

Hematemesis: Expulsion of blood in vomitus.
Source: Indicates upper gastrointestinal (UGI) bleeding proximal to ligament of Treitz (duodenojejunal flexure).
Appearance: Bright red or "coffee-ground".
Mechanism of Coffee-Ground: Degradation of heme by gastric acid signifies prolonged contact with gastric secretions.
Associated Presentation: May present with melena (black tarry stools) or hematochezia (bright red blood per rectum) if transit is rapid.

Age Group	Common Causes	Rare/Other Causes
Neonate/Infant	Swallowed maternal blood, Vitamin K deficiency (Hemorrhagic disease of newborn), Reflux esophagitis, Gastroduodenal erosions/ulcers (stress/sepsis).	Vascular malformations, Esophageal varices (>3-4 months), Duplication cyst, Cow milk allergy, Teratoma.
Preschool (2–5 yr)	Vomiting-induced (Mallory-Weiss tear, prolapse gastropathy), Acid-peptic disease, Esophageal varices (liver disease), Hemorrhagic gastritis, Caustic ingestion.	Bowel obstruction, Foreign body.
Older Child/Adolescent	Acid-peptic disease, Esophageal varices (liver disease), Mallory-Weiss tear, Reflux esophagitis, Hemorrhagic gastritis, Stress ulcer.	IgA vasculitis (Henoch-Schönlein purpura), Dieulafoy lesion, Hemobilia, Hemosuccus pancreaticus, Leiomyoma, Lymphoma.

Pathology	Clinical Features & Nuances
Esophageal/Gastric Varices	Painless, massive bleeding. Associated with portal hypertension, splenomegaly, ascites, caput medusae, cirrhosis, or extrahepatic portal venous obstruction (EHPVO).
Peptic Ulcer Disease (PUD)	Epigastric pain, nausea, weight loss. Associated with Helicobacter pylori, NSAID use, corticosteroids. Secondary ulcers linked to stress (Cushing/Curling ulcers).
Mallory-Weiss Syndrome	Mucosal tear at gastro-esophageal junction. History of nonbloody emesis/severe retching eventually converting to hematemesis. Self-limiting.
Swallowed Maternal Blood	Seen in neonates/breastfeeding infants. Bleeding from maternal nipple or swallowed during delivery. Diagnosed via Apt-Downey test (differentiates fetal from adult hemoglobin).
Foreign Body / Caustic Ingestion	History of ingestion. Dysphagia, drooling, stridor. Button batteries mandate emergent removal (<2 hours).
Dieulafoy Lesion	Abnormally enlarged submucosal arteriole. Presents as massive, abrupt GI hemorrhage in otherwise healthy child.

Hemodynamic Assessment: Assess for shock, tachycardia, hypotension, orthostatic changes (increase in pulse >20 beats/min or decrease in systolic BP >10 mm Hg upon sitting).
Physical Examination: Look for splenomegaly (most specific finding for varices in children). Check for jaundice, ascites, palmar erythema, spider nevi (chronic liver disease).
Nasogastric (NG) Lavage: Normal saline lavage confirms UGI source and assesses for active, ongoing bleeding. Transpyloric (duodenal) bleeding may be missed.
Apt-Downey Test: Mandatory in neonates/nursing infants to exclude swallowed maternal blood.

Complete Blood Count (CBC): Baseline hemoglobin/hematocrit (may underestimate initial blood loss). Platelet count (thrombocytopenia in hypersplenism).
Coagulation Profile: Prothrombin time (PT), Partial thromboplastin time (PTT), International normalized ratio (INR).
Liver & Renal Chemistry: Transaminases, albumin, bilirubin. BUN/Creatinine ratio often elevated in UGI bleed (blood protein digestion).
Blood Bank: Type and crossmatch immediately.

Esophagogastroduodenoscopy (EGD): Initial diagnostic procedure of choice. Provides direct visualization, identifies bleeding site, allows immediate therapeutic intervention. Contraindicated in hemodynamically unstable patients until resuscitated.
Doppler Ultrasound: Essential for evaluating portal/hepatic vein patency, splenic size, and intra-abdominal abnormalities.
CT/Conventional Angiography: Indicated for brisk, ongoing bleeding (>0.5 mL/min) when EGD fails or is contraindicated. Allows for selective microcoil embolization.

Maintain patent airway, oxygen supplementation.
Establish two large-bore intravenous (IV) cannulas.
Rapid volume replacement with isotonic crystalloids (Normal Saline).
Blood Transfusion: Administer packed red blood cells (PRBCs). Target hemoglobin: 7 to 9 g/dL. Avoid over-transfusion to prevent rebound increase in portal pressure.
Correct Coagulopathy: Administer Vitamin K, Fresh Frozen Plasma (FFP), or platelets as indicated.

Bleeding Type	Medications & Dosing	Rationale
Non-Variceal	Proton Pump Inhibitors (PPIs): IV Pantoprazole 2 mg/kg loading dose (max 80 mg), followed by 0.2 mg/kg/hr continuous infusion.	Raises intragastric pH, stabilizes clot formation, heals erosions/ulcers.
Variceal	Octreotide (Somatostatin analog): 1 mcg/kg IV bolus, followed by 1.0–5.0 mcg/kg/hr continuous infusion. Maintain for 24-48 hours post-bleeding cessation.	Splanchnic vasoconstriction; decreases portal venous flow and pressure.
Variceal	Antibiotic Prophylaxis: 3rd-generation cephalosporin (e.g., Ceftriaxone) for 7 days.	Reduces bacterial infection and mortality in cirrhotic patients with GI bleed.

Timing: Perform within 12 hours of bleed onset, post-stabilization.
Variceal Bleeding:
- Endoscopic Variceal Ligation (EVL): Procedure of choice (preferred over sclerotherapy due to lower rebleeding risk). O-ring strangulates varix causing fibrosis.
- Endoscopic Sclerotherapy (EST): Injection of 1% ethoxysclerol or sodium tetradecyl sulfate into variceal column. Used in smaller infants where EVL device cannot fit.
- Tissue Glue: N-butyl-2-cyanoacrylate injection. Standard for massive gastric varices.
Non-Variceal Bleeding:
- Electrocoagulation (bipolar/heater probe), Argon plasma coagulation (APC).
- Epinephrine injection, endoscopic clips (hemoclips), or hemostatic powder.

Balloon Tamponade: Sengstaken-Blakemore tube. Triple-lumen tube with esophageal and gastric balloons to mechanically compress bleeding varices. Used only as a temporary bridge.
TIPS (Transjugular Intrahepatic Portosystemic Shunt): Interventional radiology establishes metallic stent between portal vein and hepatic vein. Bypasses liver resistance. Indicated for refractory variceal hemorrhage.
Surgical Shunts: Meso-Rex bypass, portocaval shunt, or devascularization with esophageal staple transection for cases failing endoscopic/radiologic management.