Vomiting blood

What is vomiting blood (haematemesis)?

The medical word for vomiting blood (or throwing up blood) is haematemesis. Vomiting blood is usually a sign of a problem within the upper gut. That is, the gullet (oesophagus), stomach or the first part of the gut (small intestine) known as the duodenum. There is a range of different causes - discussed below.

What are the causes of vomiting blood?

Common causes of throwing up blood include:

• A stomach ulcer.

• Alcoholic liver disease.

• A tear in your gullet (oesophagus) caused by prolonged retching.

• Swallowed blood from a nosebleed.

Vomiting blood always needs to be checked out by a doctor and may need emergency treatment in hospital.

Bleeding from the oesophagus

Causes include:

• Oesophageal varices. Varices are enlarged, swollen blood vessels in the lining of the gullet or stomach. They are one of the possible complications of liver cirrhosis. In cirrhosis, scarred liver tissue blocks blood flow through the liver. This causes an increase in pressure in the vein that takes blood from the gut to the liver (the portal vein). The increased pressure pushes back into the gut and causes the veins to swell in the gullet. The swellings are quite fragile and may bleed heavily into the gullet.

• Inflammation of the oesophagus (oesophagitis) is often due to acid reflux from the stomach (gastro-oesophageal reflux disease (GORD)). The inflamed oesophagus sometimes bleeds.

• Oesophageal cancer sometimes causes bleeding into the oesophagus.

• Mallory-Weiss syndrome is bleeding caused by a tear in the lining of the oesophagus or stomach. The tear can be caused by anything that leads to a sudden rise in pressure in the stomach or the oesophagus. For example, repeated retching or vomiting, excessive straining, violent coughing or hiccupping.

Bleeding from the stomach

Causes include:

• Stomach (gastric) ulcer. An ulcer is a small breakdown in the lining of the stomach. An ulcer may bleed, sometimes heavily. There are several causes of stomach ulcers, including:

  • Infection with a germ (bacterium) called Helicobacter pylori. This can usually be treated quite easily.

  • Anti-inflammatory medicines that are used to treat conditions such as arthritis, sometimes cause stomach ulcers.

  • Aspirin, used commonly to prevent blood clots.

  • Stress.

• Stomach cancer sometimes causes bleeding into the stomach.

• Inflammation of the stomach lining (gastritis) has similar causes to stomach ulcers.

• Varices in the lining of the stomach may occur similar to oesophageal varices described above.

• Mallory-Weiss syndrome may affect the lining of the stomach - described above.

Bleeding from the duodenum

Causes include:

• Duodenal ulcer. An ulcer may bleed, sometimes heavily. Like stomach ulcers, a duodenal ulcer is usually caused by an infection with the germ (bacterium) called H. pylori. This can usually be treated quite easily. Anti-inflammatory medicines and aspirin, which are common causes of stomach ulcers, are uncommon causes of duodenal ulcers.

• Inflammation of the duodenum lining (duodenitis) has similar causes to duodenal ulcers.

Rare causes from any part of the upper gut

Include:

• Radiation poisoning.

• Uncommon infections of the gut (gastrointestinal tract).

• Injury.

• No cause identified. Even after tests, in some cases the cause cannot be found.

Bleeding which has not come from the gut

Sometimes when blood is vomited, it has not come from the gut. For example, if you have had a nosebleed and then swallowed the blood, you may vomit blood. Also sometimes it can be difficult to tell whether the blood has been vomited up from the gut, or coughed up.

A note about anticoagulants

Medicines like warfarin or the newer oral anticoagulants (such as rivaroxaban, apixaban and dabigatran - often called DOACs) are not thought to cause bleeding, but if you are bleeding they will make the bleeding worse.

The upper gut

Symptoms alongside vomiting blood

Other symptoms may occur at the same time as vomiting blood such as:

• Tummy (abdominal) pain.

• High temperature (fever).

• Feeling unwell.

• Dizziness.

• Fainting.

• Other gut symptoms.

The presence and type of other symptoms may help to point to a cause of the bleeding. Sometimes there are no other symptoms at first.

What tests may be needed if I'm vomiting blood

A clinician's assessment

They are likely to ask various questions about the nature of the bleeding and ask if you have any other symptoms. They will also examine you.

Their aim is to try to find out if this blood is truly coming from the upper gut. Sometimes it is difficult to be sure. Sometimes it can be difficult to say if the blood is:

• Haemoptysis - that is, if the blood is coughed up, not vomited up.

• Coming from somewhere in your mouth or nose that tracks to the back of your throat, which you then swallow and vomit back up. For example, from a nosebleed.

The clinician will also try to make a judgement about how much blood you have lost and how serious this is. They will be able to tell this from what you tell them and also by checking your pulse and blood pressure.

If it is clear that the blood is coming from the upper gut, tests are usually done to identify the cause.

Blood tests

Blood tests will usually be done to assess your general situation. For example, how much blood you have lost, and if you need intravenous fluid or a blood transfusion to counter any large amount of blood loss. Also, blood tests may help to assess your liver function if you have 'scarring' of the liver (cirrhosis), or to help diagnose or assess other causes of the bleeding.

Gastroscopy

A gastroscopy (endoscopy) is an internal examination.It involves examining the inside of your digestive tract, using a thin, flexible tube that has a light and camera at one end. The telescope is passed down the gullet (oesophagus) into the stomach and to the upper duodenum. The cause of the bleeding can often be identified by endoscopy.

Treatment for vomiting blood

Initial treatment

The initial treatment may require a drip into a vein to give you fluid, or even a blood transfusion if you have lost a lot of blood. This may not be necessary if the bleeding has been minor and has stopped. However, if the bleeding is severe, full resuscitation and emergency fluid/blood replacement may be required.

Other treatments

This will depend on the cause. However, stopping the bleeding can often be done by using instruments that can be passed down the endoscope. Occasionally, emergency surgery is needed to control severe ongoing bleeding. Once bleeding has stopped, further treatment depends on the cause. For details, see individual leaflets on the various diseases that can cause vomiting blood.

Types of bleeding from the upper gut

The type of bleeding is sometimes described as follows:

Dark blood

This is often referred to as a 'coffee ground' colour. This suggests that the bleed has been relatively slow. The blood has been in contact with stomach acid long enough for the acid to turn the blood a dark brown/red colour. The bleeding in this situation may not yet have been heavy. However, it may become heavy at a later time.

A large amount of bright red blood suggests a rapid and large bleed.

Melaena

This is the medical word for old, dark blood in stools (faeces). If you have melaena, your stools become very dark or black. There is often a tar-like consistency. Vomiting blood and having melaena are symptoms that often go together. Having both symptoms together means that you have had a lot of bleeding into the gut.