Primary Causes of Hematemesis
The most common causes of hematemesis are peptic ulcer disease (35-50%), gastroduodenal erosions (8-15%), esophagitis (5-15%), esophageal varices (5-10%), and Mallory-Weiss tears (15%) 1, 2.
Definition and Clinical Significance
Hematemesis is defined as vomiting of fresh red blood, while coffee ground vomiting refers to vomiting of altered black blood 1. It is the cardinal sign of upper gastrointestinal bleeding and requires prompt evaluation and management.
Major Causes of Hematemesis
1. Peptic Ulcer Disease (35-50%)
- Most common cause of upper GI bleeding in Western countries
- Associated with H. pylori infection, NSAID use, and stress
2. Gastroduodenal Erosions (8-15%)
- Associated with:
- NSAID use
- Alcohol consumption
- Physiological stress
3. Esophagitis (5-15%)
- Primarily caused by gastroesophageal reflux disease
- Can lead to significant bleeding in severe cases
4. Esophageal or Gastric Varices (5-10%)
- More common in patients with cirrhosis and portal hypertension
- Associated with higher mortality (up to 30%) compared to other causes 3
- May be the leading cause in tropical countries like India 4
5. Mallory-Weiss Tear (15%)
- Mucosal lacerations at the gastroesophageal junction
- Typically caused by forceful vomiting or retching
- Often self-limiting
6. Less Common Causes
- Upper gastrointestinal malignancy
- Vascular malformations (1%)
- Hemobilia and hemosuccus pancreaticus (rare)
- Aortoenteric fistula (rare but potentially catastrophic) 2
- Coagulopathy-induced bleeding
Clinical Presentation and Severity Assessment
Severity of hematemesis can be categorized as:
- Massive bleeding: Patient in shock requiring >1000 ml of blood/plasma expander within one hour or >2000 ml within 24 hours, with hemoglobin ≤8.0 g/dl 5
- Moderate bleeding: Requires blood transfusion but without shock
- Mild bleeding: No significant hemodynamic compromise
Natural History and Outcomes
- Upper GI bleeding ceases spontaneously in approximately 75-88% of cases 2, 6
- Mortality remains significant (6-14%) 6
- Patients presenting with both hematemesis and melena generally have more severe bleeding than those with melena alone 1
- Three-quarters of recurrent bleeding occurs within two days of the initial hemorrhage 3
Risk Factors
- Advanced age
- Anticoagulant use
- High-dose NSAID use
- H. pylori infection
- Alcohol consumption
- Smoking
- Pre-existing liver disease
Clinical Pearls and Pitfalls
- The diagnostic yield of endoscopy is highest when performed within 36 hours of bleeding onset 3
- Only a small percentage (6%) of patients with hematemesis require therapeutic endoscopic intervention 6
- Surgical or interventional radiologic procedures are rarely needed for upper GI bleeding in the modern era 6
- Patients with variceal bleeding have a higher risk of massive hemorrhage and mortality 4
- Rare but catastrophic causes like aortoenteric fistula should be considered in patients with a history of aortic surgery or aneurysm 7
Understanding these causes and their relative frequencies helps in prioritizing diagnostic approaches and implementing appropriate management strategies for patients presenting with hematemesis.