What could be the cause of throwing up blood clots?

Vomiting Blood Clots: Emergency Evaluation and Management

Vomiting blood clots (hematemesis) indicates acute upper gastrointestinal bleeding that requires immediate medical evaluation, as this carries a mortality risk exceeding 10% and demands urgent endoscopy within 24 hours to identify and treat the bleeding source. 1, 2

Immediate Life-Threatening Causes to Consider

The most critical bleeding sources include:

• Peptic ulcer disease (most common cause) - particularly ulcers with exposed blood vessels that have a 43% rebleeding rate within 72 hours without intervention 3, 2
• Esophageal or gastric varices - carries up to 30% mortality and requires immediate vasoactive therapy (terlipressin) if cirrhosis is suspected 1, 4
• Mallory-Weiss tears - typically self-limited but can cause severe hemorrhage 1
• Gastric malignancy - particularly in older patients with weight loss 1
• Vascular malformations including Dieulafoy lesions 1

Critical Initial Assessment

Hemodynamic Stability Markers

Calculate the shock index (heart rate ÷ systolic blood pressure) - if >1, this indicates hemodynamic instability requiring ICU admission 5. Look for:

• Tachycardia, hypotension, altered mental status 5
• Signs requiring >1,000 mL blood/plasma within one hour or >2,000 mL within 24 hours define massive bleeding 3
• Hemoglobin ≤8.0 g/dL with shock indicates life-threatening hemorrhage 3

High-Risk Features Requiring Aggressive Intervention

• Active hematemesis with cardiovascular instability - proceed directly to resuscitation and urgent endoscopy 1, 2
• Peritoneal signs or abdominal distension - suggests perforation or bowel ischemia requiring emergency surgery 5
• Known cirrhosis or suspected varices - mortality approaches 30% 4
• Anticoagulant use (warfarin, DOACs) - increases bleeding risk substantially 6

Immediate Management Protocol

Resuscitation (First Priority)

• Transfusion threshold: hemoglobin <70 g/L (target 70-100 g/L), but use <90 g/L threshold if cardiovascular disease is present 1
• Initiate large-bore IV access and aggressive crystalloid resuscitation 5
• Correct coagulopathy: fresh frozen plasma if INR >1.5, prothrombin complex concentrate for warfarin reversal 1, 6
• Target fibrinogen >1.5 g/L and platelets >75 × 10⁹/L in active bleeding 1

Pharmacological Therapy

Administer high-dose intravenous proton pump inhibitor (omeprazole 80 mg bolus, then 8 mg/hour infusion) immediately before endoscopy - this reduces rebleeding rates, transfusion requirements, and hospital stay 1, 2.

If cirrhosis/varices suspected, give terlipressin immediately 1.

Urgent Endoscopy Timing

• Within 24 hours for all patients - success rate is highest within first 36 hours 4, 2
• Immediate endoscopy (<12 hours) if hemodynamically unstable, ongoing hematemesis, or suspected variceal bleeding 1, 2

Endoscopic Treatment Options

For peptic ulcers with high-risk stigmata (active bleeding, visible vessel, adherent clot):

• Combination therapy is superior: dilute adrenaline injection PLUS thermal coagulation (heater probe/BICAP) or mechanical clips 1, 2
• Adrenaline injection alone is insufficient for high-risk ulcers 1
• Avoid sclerosants (can cause life-threatening necrosis) and absolute alcohol (perforation risk) 1

For varices: endoscopic band ligation preferred over sclerotherapy 2

Anticoagulant Considerations

Warfarin Reversal

Patients on warfarin have significantly increased bleeding risk, particularly with INR >4.0, age ≥65, history of GI bleeding, or concomitant NSAIDs 6.

Reverse immediately with prothrombin complex concentrate (dose based on INR: 25 units/kg for INR 2-3.9,35 units/kg for INR 4-5.9,50 units/kg for INR >6) plus intravenous vitamin K 5-10 mg 1.

Direct Oral Anticoagulants (DOACs)

Critical limitation: dabigatran, rivaroxaban, apixaban, and edoxaban cannot be reversed with standard agents 1. Supportive care with transfusion and prothrombin complex concentrate may provide partial benefit.

When Surgery is Required

Immediate surgical consultation if:

• Hemodynamic instability despite aggressive resuscitation 5
• Failed endoscopic therapy or rebleeding after repeat endoscopy 2
• Peritoneal signs, pneumoperitoneum, or suspected perforation 5
• Persistent bleeding requiring >6 units packed red blood cells 1

Common Pitfalls to Avoid

• Do not delay endoscopy - mortality increases significantly after 36 hours 4
• Do not use H2-receptor antagonists - they do not reliably raise gastric pH above 6 and are ineffective 1
• Avoid vasopressors if possible in suspected mesenteric ischemia - they worsen bowel perfusion 5
• Do not perform routine phlebotomy in cyanotic patients unless severe hyperviscosity symptoms with hematocrit >65% 1
• Never assume bleeding has stopped - 25% rebleed after initial cessation, mostly within 48 hours 4

Post-Stabilization Monitoring

Admit to critical care for:

• Continuous hemodynamic monitoring 1
• Serial hemoglobin, coagulation studies, and blood gases 1
• Venous thromboprophylaxis once bleeding controlled (patients rapidly develop prothrombotic state) 1