Hematemesis: Causes, Symptoms, Prevention, and Treatment
What is Hematemesis?
Hematemesis refers to the vomiting of bright red blood or coffee-ground-like material that originates from the upper gastrointestinal (GI) tract. It is always considered a serious symptom and requires urgent medical evaluation because it indicates active bleeding somewhere between the mouth and the ligament of Treitz (the junction between the duodenum and jejunum).
Even small amounts of blood in vomit should never be ignored. In many cases, hematemesis is a sign of a life-threatening condition that can rapidly lead to hypovolemic shock if not treated promptly.
How Much Blood Loss is Dangerous?
Mild hematemesis: < 50–100 mL (may appear as blood streaks or coffee-ground vomitus) - Moderate: 200–500 mL - Severe/Massive: > 500–1000 mL in a short period → can cause hemodynamic instability within minutes
Massive upper GI bleeding has a mortality rate of 8–15% even with modern care, emphasizing the need for rapid intervention.
Common Causes of Hematemesis (Ranked by Frequency in 2025)
1.Peptic Ulcer Disease (PUD) – 35–50% of cases
– Most common cause worldwide
– Duodenal ulcers bleed more frequently than gastric ulcers
– Risk factors: H. pylori infection, NSAID/aspirin use, stress ulcers
2. Gastroesophageal Varices– 15–30%
– Seen in portal hypertension (cirrhosis, portal vein thrombosis)
– Highest mortality (15–25%) due to massive bleeding tendency
3. Mallory-Weiss Tear – 5–15%
– Longitudinal mucosal tears at the gastroesophageal junction
– Classic history: severe retching/vomiting → sudden hematemesis
4. Acute Erosive Gastritis / Stress Ulcers – 10–20%
– Alcohol binge, NSAIDs, critical illness (ICU patients)
5. Esophagitis (Reflux or Infectious) – 5–10%
6. Dieulafoy’s Lesion– < 5%
- Aberrant submucosal artery that erodes and bleeds catastrophically
7.Upper GI Malignancy (gastric/esophageal cancer) – 3–7%
8. Aortoenteric Fistula – Rare but lethal
- Usually after aortic graft surgery; sudden massive hematemesis
9. Hemobilia / Hemosuccus Pancreaticus – Very rare
- Bleeding from biliary or pancreatic duct
10.Vascular Malformations (Angiodysplasia, GAVE)
Signs and Symptoms of Hematemesis
Primary Symptom
- Vomiting bright red blood (fresh bleeding)
- Vomiting dark “coffee-ground” material (partially digested blood)
Associated Symptoms
- Melena (black tarry stools) – present in >90% of significant upper GI bleeds
– Syncope or near-syncope
– Dizziness, cold sweats, palpitations
– Abdominal pain (epigastric or diffuse)
– Hematochezia (bright red blood per rectum) – only if bleeding is extremely brisk (>1000 mL)
Signs of Hypovolemia / Shock
– Tachycardia (>100 bpm)
– Hypotension (systolic <90 mmHg)
- Oliguria
- Altered mental status
- Cool, clammy extremities
Rockall Score & Blatchford Score
Clinicians use these validated scoring systems at presentation to predict mortality and need for intervention.
Red Flags – When to Go to ER Immediately
- Large volume of bright red blood
- Syncope or near-syncope
- Signs of shock
- Known varices or cirrhosis
- Ongoing alcohol abuse + vomiting
- History of aortic graft surgery
- NSAID or anticoagulant use
Do NOT wait at home.** Call emergency services
Diagnostic Approach in 2025
1.Immediate Stabilization
- Two large-bore IV lines
- Fluid resuscitation (crystalloids → blood if needed)
- Correct coagulopathy (INR >1.5 → FFP or PCC
2. Blood Tests
– CBC (hemoglobin drop may be delayed)
– BUN:Creatinine ratio >30 suggests upper GI source
– LFTs, coagulation profile, type & cross
3. Upper Endoscopy (EGD) – Gold standard
– Performed within 12–24 hours (within 12 h if variceal or unstable)
– Allows diagnosis + therapy in the same session
4. CT Angiography
– If endoscopy fails or patient too unstable
5. Tagged RBC Scan or Angiography
– For obscure or ongoing bleeding
Treatment of Hematemesis (2025 Guidelines)
A. General Measures
– NPO (nothing by mouth)
– IV proton pump inhibitor (PPI) bolus + infusion (pantoprazole 80 mg → 8 mg/h)
– Blood transfusion if Hb <7 g/dL (or <8 in cardiac disease)
- Correct coagulopathy:
- Warfarin → PCC + vitamin K
- DOACs → specific reversal agents (idarucizumab, andexanet alfa)
- Antiplatelets → consider platelet transfusion if life-threatening
B. Specific Therapy According to Cause
| Cause | First-Line Treatment | Second-Line / Rescue |
|------------------------|---------------------------------------------------|------------------------------------------|
| Peptic Ulcer (Forrest Ia/Ib) | Endoscopic hemostasis (injection + clips/band/OTC) + high-dose PPI | Angiographic embolization or surgery |
| Variceal Bleeding | IV octreotide/terlipressin + antibiotics (ceftriaxone) + endoscopic band ligation | TIPS (transjugular intrahepatic portosystemic shunt) |
| Mallory-Weiss Tear | Usually self-limited; endoscopic therapy if active bleeding | Rarely surgery |
| Dieulafoy Lesion | Endoscopic clipping or band ligation | Angiography + embolization |
Newer 2024–2025 Tools
- Over-the-scope clips (OTSC) – higher success in refractory bleeding
- Hemospray/EndoClot – topical hemostatic powders
- Doppler endoscopic probe – confirms vessel eradication
Prevention of Hematemesis
1. Peptic Ulcer Prevention
- Test and treat H. pylori in high-risk populations
- Avoid chronic NSAID use without gastroprotection (PPI or misoprostol)
- Limit alcohol and smoking
2. Variceal Bleeding Prevention
- Primary prophylaxis in cirrhosis:
- Non-selective beta-blockers (carvedilol preferred in 2025) or
- Endoscopic variceal ligation (EVL) for large varices
- Treat underlying liver disease aggressively
3. General Measures
- Avoid binge drinking and forceful vomiting
- Use NSAIDs sparingly; always take with food or PPI
- Vaccination against hepatitis B
- Limit aspirin in low-cardiac-risk individuals
Prognosis & Mortality (2025 Data)
- Overall 30-day mortality: 8–12%
- Variceal bleeding: 15–25%
- Peptic ulcer bleeding: 5–10%
- Re-bleeding rate without intervention: 60% (varices), 20–30% (ulcers)
Early endoscopy + modern hemostatic techniques have significantly reduced mortality over the last decade.
Frequently Asked Questions (FAQs)
Q1. Is coffee-ground vomit always blood?
A. Almost always. Coffee-ground appearance is due to partially digested hemoglobin. False positives are rare (iron tablets, beets, bismuth).
Q2. Can hematemesis occur without pain?
A. Yes. Variceal bleeding and Dieulafoy lesions are often painless.
Q3. How much blood in vomit is considered serious?
A. Any visible blood is serious. Even 50 mL can indicate significant pathology.
Q4. Should I drive myself to the hospital if vomiting blood?
A. No. Call an ambulance. You can become unstable rapidly.
Q5. Will a single episode of hematemesis resolve on its own?
A. Mallory-Weiss tears often stop spontaneously, but you still need urgent evaluation to rule out other causes.
Q6. Are there any home remedies for vomiting blood?
A. Absolutely not. This is a medical emergency. Do not drink milk, take antacids, or wait.
Q7. Is hematemesis more common in alcoholics?
A. Yes – due to gastritis, varices, and Mallory-Weiss tears.
Q8. Can stress alone cause vomiting blood?
A. Stress ulcers in critically ill patients (ICU) can, but emotional stress alone rarely does.
Q9. What foods should I avoid after an episode?
A. After stabilization: avoid spicy, acidic, rough foods, alcohol, and NSAIDs until cleared by gastroenterologist