Vomiting Blood

This presentation may vary from a few red streaks in gastric fluid to copious quantities of bright red blood. Blood static in the stomach for a few hours will change to look dark and granular, like coffee grounds. Always do a full urgent assessment, and be prepared for the sudden need for resuscitation.

Published: 1st August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • Peptic Ulcer (PU)/Acute Gastritis
  • Mallory–Weiss (M–W) Tear
  • Oesophageal Varices (Cirrhosis, Usually Alcoholic)
  • Malignancy: Oesophagus or Stomach
  • GORD

Occasional Diagnoses

  • Swallowed Blood (Nose Bleeds Obvious, Haemoptysis Less So)
  • Foreign Body or Mediastinal Tumour Perforating Oesophagus and Aorta (Including Aneurysm)
  • Haemobilia (Blood in Bile)
  • Ingested Poisons: Corrosive Acid and Alkali, Arsenic
  • Blood Dyscrasias (e.g. Thrombocytopenia, Leukaemia, Haemophilia, Aplastic Anaemia)

Rare Diagnoses

  • Ruptured Oesophagus (Acute Vomiting or Trauma)
  • Spurious: Deliberate Swallowing and Vomiting of Blood (Munchausen’S Syndrome)
  • Gallstone Perforation of Duodenum
  • Scurvy
  • Polyarteritis Nodosa, Systemic Lupus Erythematosus (SLE)

Ready reckoner

Key distinguishing features of the most common diagnoses

PUM–W TearVarices CancerOesophagitis
History of Weight LossPossibleNoPossibleYesNo
Preceded by VomitingPossibleYesNoNoNo
Preceded by MelaenaPossibleNoPossiblePossiblePossible
Severe PainYesPossibleNoPossibleYes
Signs of Shock LikelyYesNoYesPossibleNo

Possible investigations

  • These will be done acutely in hospital, or in general practice after an episode of haematemesis when urgent admission is not indicated.
  • FBC: Essential for assessment of the degree of blood loss. A normal Hb does not exclude a serious bleed as haemodilution may take several hours. Will also reveal blood dyscrasias. Raised platelets associated with oesophageal or stomach cancer.
  • Upper gastrointestinal (GI) endoscopy is the gold standard for finding the cause of the bleed and biopsy of suspicious lesions.
  • Helicobacter testing: In the presence of peptic ulceration.
  • LFT and γGT to assess liver function. Alcohol is a significant contributory factor in many cases.
  • Plain erect abdominal X-ray (in hospital) useful to look for signs of viscus perforation (air under diaphragm) and, rarely, an ectopic gallstone.

Top Tips

  • Take a careful history – patients often confuse vomiting up and coughing up blood.
  • If about to visit, ask the patient not to dispose of the evidence – viewing the vomit is worth a thousand words of history.
  • Don’t forget the relevance of the patient’s drug history – non-steroidal anti-inflammatory drugs (NSAIDs), steroids and warfarin may all be associated with acute gastric erosions.

Red Flags

  • Tachycardia may be the only physical sign of a significant GI bleed.
  • In all acute cases, admit unless the patient is perfectly well and the cause obvious and insignificant (e.g. swallowed blood or very minor Mallory–Weiss tear).
  • The patient may not realise the significance of coffee-ground vomit or melaena – enquire specifically about these symptoms.
  • Troisier’s sign (enlargement of the left supraclavicular node) strongly suggests malignancy.
  • Oesophageal varices account for only 5% of cases, but 80% of mortality. Call for an ambulance immediately and secure intravenous (IV) access if possible.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.