From the Guidelines
Hematemesis and hematochezia are two distinct clinical presentations of gastrointestinal bleeding, with hematemesis typically indicating upper GI bleeding and hematochezia usually signifying lower GI bleeding, although massive upper GI bleeding can sometimes present as hematochezia due to rapid transit. Hematemesis refers to vomiting blood, often appearing as "coffee-ground" material when partially digested, and is commonly caused by peptic ulcers, gastritis, esophageal varices, and Mallory-Weiss tears 1. On the other hand, hematochezia is the passage of fresh, bright red blood from the rectum, usually indicating lower GI bleeding from sources such as hemorrhoids, diverticulosis, inflammatory bowel disease, and colorectal cancer.
Initial Management
Initial management of both conditions includes hemodynamic stabilization with IV fluids, such as normal saline or lactated Ringer's, and blood pressure monitoring, with possible blood transfusions if hemoglobin drops below 7-8 g/dL 1. It is crucial to prioritize the patient's hemodynamic stability before attempting to identify and treat the source of bleeding.
Diagnostic Approaches
Diagnostic approaches differ between hematemesis and hematochezia. For hematemesis, upper endoscopy is the preferred diagnostic method, as it allows for direct visualization of the upper GI tract and potential treatment of the bleeding source 1. In contrast, colonoscopy is the diagnostic method of choice for hematochezia, as it enables visualization of the lower GI tract and potential treatment of the bleeding source 1. However, if massive hematochezia is suspected to originate from an upper GI source, upper endoscopy may be performed first.
Treatment
Treatment targets the specific bleeding source, whether it's proton pump inhibitors and endoscopic therapy for upper GI bleeding or colonoscopic interventions for lower GI sources 1. The distinction between hematemesis and hematochezia is crucial, as it guides the choice of diagnostic and therapeutic approaches. According to the most recent guidelines, for a hemodynamically stable patient with lower GIB and active bleeding clinically observed as hematochezia or melena, CTA of the abdomen and pelvis without and with IV contrast, diagnostic/therapeutic colonoscopy, or RBC scan abdomen and pelvis is usually appropriate as the next step 1.
From the Research
Definition and Presentation
- Hematemesis refers to the vomiting of blood, typically indicating upper gastrointestinal bleeding 2, 3, 4.
- Hematochezia refers to the passage of fresh blood per rectum, usually indicating lower gastrointestinal bleeding 5, 6, 3, 4.
Causes and Risk Factors
- Hematochezia can be caused by diverticulosis, angiodysplasia, neoplasm, perianal disorders, and other conditions 6.
- Upper gastrointestinal bleeding, which can present as hematemesis, can be caused by peptic ulcers, esophageal varices, and other conditions 2, 3.
- Cirrhosis is a risk factor for upper gastrointestinal bleeding, and patients with cirrhosis are more likely to experience severe hematochezia with an upper gastrointestinal source of bleeding 3.
Diagnosis and Management
- A step-wise approach to hematochezia can help determine the cause and provide appropriate management, including hemodynamic assessment, risk stratification, focused history and physical examination, and endoscopic intervention when warranted 5.
- Accurate clinical diagnosis is crucial in guiding definitive investigations and interventions for gastrointestinal bleeding 4.
- The use of proton pump inhibitors, such as omeprazole, can decrease the rate of rebleeding in patients with bleeding peptic ulcers 2.