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Hematemesis and Causes of Vomiting Up Blood

What is hematemesis?

Hematemesis (UK ~ haematemesis) is the medical term for the vomiting of blood either mixed with partially digested gastrointestinal contents and mucus or consisting entirely of blood. Blood in the vomit can vary in color from fresh and bright red to degraded maroon blood or even dark brown to black vomit resembling coffee grounds. Clots may be clearly visible in the vomit. Hematemesis may be associated with melena, which are black, tarry stools, as a result of an upper gastrointestinal bleed.

Color of Blood Vomit

Bleeding from any site above the lower esophageal sphincter (LES) usually appears red and ‘fresh’. This may also be seen when there is profuse bleeding thereby preventing the action of gastric enzymes, particularly pepsin, from degrading the blood. Maroon to dark brown or black blood in the vomit is more likely to originate from the stomach or duodenum. Due to the process of vomiting, it is possible that black coffee ground blood may have forced up from as far down as the jejunum or proximal parts of the ileum of the small intestine.

Other Symptoms

  • Upper GI bleeding may also result in melena (dark blood in the stool) or if the bleeding is profuse, even hematochezia (fresh blood in the stool) may be noted.
  • Mild GI bleeding that is prolonged or excessive bleeding may result in anemia, hypotension (low blood pressure), dizziness and fainting.
  • Abdominal pain may also be noticed especially if the bleeding is due to peptic ulcers, erosive gastritis, Mallory-Weiss tear or chemical poisoning.
  • Hematemesis accompanied by the collection of fresh blood in the mouth may be indicative of a rupture of esophageal varices.
  • Vomiting non-bloody vomitus or retching may be followed by a bloody vomit which would indicate a Mallory-Weiss tear or rupture of esophageal varices as a result of the preceding forceful vomiting or retching.

The presence of blood in the vomit (hematemesis) is an indication of bleeding within the upper gastrointestinal tract -  esophagus, stomach and duodenum. It may vary from blood mixed with food, water and/or mucus or in severe cases, the vomit may be composed almost entirely of blood. As the blood clots and degrades, the appearance changes from a ‘fresh’, bright red color to a dark brown and even black coagulated mass resembling coffee grounds.

Hematemesis is often associated with melena, which is a black tarry stool as a result of the degradation of blood as it passes through the gut.

Location of the Bleed

The color and consistency of the blood in the vomit provides some indication of the site of the bleed. Vomiting fresh, fluid and bright red blood indicates bleeding from a site proximal to the lower esophageal sphincter (LES). This most likely originates from within the esophagus.

Dark brown or black blood, appearing as a coagulated mass (clots) resembling coffee grounds, indicates bleeding from the stomach or duodenum. The action of pepsin secreted by the stomach lining degrades the blood. This is further altered by digestive enzymes from the intestinal wall and pancreas.

Bleeding in the pharynx, mouth or nasal cavity may also be responsible for blood entering the gastrointestinal tract or respiratory tract. While this may be passed out as spitting out blood or as a nose bleed (epistaxis), it may also be passed out in vomit (hematemesis), when coughing (hemoptysis) or in stool (melena, or if rapid and profuse then hematochezia).

Causes of Bloody Vomit

  • Esophagitis
  • Esophageal cancer
  • Esophageal rupture/tear
  • Esophageal varices
  • Mallory-Weiss tear
  • Gastritis
  • Stomach cancer
  • Stomach ulcer
  • Stomach varices
  • Mallory-Weiss tear
  • Duodenitis
  • Duodenal ulcer
  • Arteriovenous malformation
  • Benign tumors of the esophagus, stomach or duodenum

Other causes

This includes contributing factors that may cause the conditions listed above.

  • Alcohol abuse
  • Cirrhosis
  • Drugs like NSAIDs (non-steroidal anti-inflammatory drugs)
  • H.pylori infection
  • Liver failure
  • Pancreatitis
  • Pancreatic cancer
  • Poisoning with ingested toxins like in arsenic poisoning
  • Portal hypertension

Certain foods and drinks may cause a red to brown or black discoloration of the vomitus. This should not be confused with hematemesis.