Hematemesis or Hemoptysis:

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Hematemesis and hemoptysis are two maladies that are frequently confused for one another. Both involve bleeding, but the source of the blood is different. When patients complain of “spitting up blood,” all bets are off with regard to source and location. It is crucial that healthcare workers determine where the blood is coming from and how much has been lost already. Stabilizing the patient is the most important step.

Hematemesis

Hematemesis is the vomiting of blood. Vomiting blood is a regurgitation of blood from the upper gastrointestinal (GI) tract, which includes the mouth, pharynx, esophagus, stomach, and the small intestine.

Annually in the U.S., about 100 people per 100,000 adult population (1 in 1,000) experience acute upper GI bleeding, and more than 350,000 are hospitalized, with an estimated overall cost of about $1 billion. Men are about twice as likely as women to have upper GI bleeding. Most GI bleeding admissions for adults are for upper GI bleeding.

Upper GI bleeding (UGIB) is defined as hemorrhage that emanates proximal to the ligament of Treitz at the duodenojejunal junction — the fourth part of the duodenum. It is a common and potentially life-threatening condition. Upper GI bleeding has an overall mortality rate of 10 percent. Although more than 75 percent of cases of bleeding cease with supportive measures, a significant percentage of patients require further intervention, which involves the combined efforts of gastroenterologists, surgeons, and interventional radiologists.

The most common causes of acute upper GI bleeding are peptic ulcer, gastritis, and esophagitis. Clinically, UGIB often causes hematemesis (vomiting up of blood) or melena (passage of stools rendered black and tarry by the presence of altered blood). When this happens soon after hemorrhage, the vomitus is bright red. The color of the vomitus depends on the contact time with the hydrochloric acid of the stomach. If vomiting occurs early after the onset of bleeding, it appears red; with delayed vomiting, it is dark red, brown or black. If blood has been retained in the stomach, digestive processes change the hemoglobin to a brown pigment, which gives the vomitus a coffee-ground appearance. The vomited blood might be mixed with food particles. The blood may be bright red if bleeding is so profuse that there has been little time for gastric juices to act on it. Conversely, the blood may have a coffee-grounds appearance if bleeding has been slower and gastric juices have converted hemoglobin to a brown breakdown product. A coffee-grounds appearance occurs with precipitated blood clots in the vomitus.

Manifestation of bleeding depends on the source, rate of bleeding, and underlying or coexistent disease — a patient with underlying ischemic heart disease may present with angina or a myocardial infarction (MI) after brisk bleeding. Acute hypovolemia or anemia secondary to chronic (overt or occult), coexistent heart failure, hypertension, pulmonary disease, renal failure, and diabetes mellitus may be aggravated by severe GI bleeding.

Upper gastrointestinal bleeding is a serious and common complaint. Quick evaluation and resuscitation coupled with endoscopic diagnosis and treatment may improve outcome.

Major bleeding is manifested by hemodynamic instability; minor bleeding is not. Acute GI bleeding is of recent duration that is less than three days.

The rate and extent of hemorrhage, coupled with the patient’s comorbidities, determines the clinical presentation of the upper GI bleed. In a patent with suspected acute GI bleeding, do not be misled by a normal or slightly decreased hematocrit and hemoglobin. It takes 48 hours for these tests to accurately reflect blood loss. Promptly evaluate hemodynamic instability and determine if urgent fluid resuscitation is required for any patient who is dizzy and weak when standing, and has a decrease in blood pressure of more than 10 mm Hg and an increase in heart rate of more than 10 beats per minute, as this represents an acute blood loss of 15 percent or more.

In a hemodynamically unstable patient, consider GI bleeding to be life-threatening until it is proven otherwise. Insert two 18 gauge or larger IV lines and start normal saline or lactated Ringer’s solution before initiating further diagnostic tests. In order of urgency, consider the goals of management to include resuscitation and stabilization — preventing the patient from bleeding out takes precedence over everything else. The next steps include identifying the anatomic level of bleeding; diagnosing the cause; and finally, providing specific therapy.

Endoscopy is a critical early intervention that can be used to establish the source of bleeding, and it also offers therapeutic options. Blood loss amounting to six units in 24 hours is usually considered “massive." If bleeding cannot be controlled by means of endoscopy, further interventions with catheter-directed embolotherapy or surgery may be warranted.

History

Ask the patient about symptoms consistent with blood loss, such as angina, shortness of breath, fatigue, or dizziness. Patients with hemodynamic instability, or with underlying cardiovascular disease and apparent ongoing bleeding, need urgent attention to fluid and blood resuscitation.

Ask about the amount, duration, and frequency of bloody stools. Although patients’ estimates of the amounts of blood loss are often inaccurate, be especially alert for cardiovascular collapse in the patient who reports frequent passage of large amounts of blood.

Ask about prior episodes of GI bleeding.

Ask about aspirin, nonsteroidal antiinflammatory drugs (NSAID), and tobacco use. Peptic ulcers are strongly associated with aspirin and or NSAID use. Smoking is also a risk factor for peptic ulcers.

Ask about liver disease and alcohol use. Patients with alcoholic cirrhosis and bleeding from esophageal varices have higher morbidity and mortality rates.

Where is it from?

GI TRACT RESPIRATORY TRACT
Dark red or brown
In clumps
Mixed with food
Acidic pH
Stomachache, abdominal discomfort
Nausea, retching before and after episode
Bright red
Foamy, runny
Mixed with mucous
Alkaline pH
Chest pain, warmth or gurgling over the chest
Persistent cough

Lab Studies

  • CBC with platelet count and differential: CBC is necessary to assess the level of blood loss. Where possible, having the patient’s previous results is useful to gauge the level of blood loss. CBC should be checked frequently (every four to six hours) during the first day.
  • Basic metabolic profile (BMP): The BMP is useful to evaluate for renal comorbidity; however, blood in the upper intestine can elevate the blood urea nitrogen (BUN) level as well.
  • Measurement of coagulation parameters: This is necessary to assess for continued bleeding. Abnormalities should be corrected rapidly. Prothrombin time/activated partial thromboplastin time.
  • Liver profile: The liver profile can identify hepatic comorbidity and suggest underlying liver disease.
  • Calcium level: A calcium level is useful to identify the patient with hyperparathyroidism as well as to monitor calcium in patients receiving multiple transfusions of citrated blood.
  • Gastrin level: A gastrin level can identify the rare patient with gastrinoma as the cause of UGIB and multiple ulcers.

Other Tests

An ECG should be ordered to exclude arrhythmia and cardiac disease, especially acute myocardial infarction due to hypotension.

Esophagogastroduodenoscopy (EGD) may increase the risk of arrhythmias.

Performing a troponin test may be useful to identify patients with severe coronary ischemia or atypical myocardial infarction.

Chest radiographs should be ordered to exclude aspiration pneumonia, effusion, and esophageal perforation; abdominal scout and upright films should be ordered to exclude perforated viscus and ileus.

Barium contrast studies are not usually helpful and can make endoscopic procedures more difficult (i.e., white barium obscuring the view) and dangerous (i.e., risk of aspiration).

Barium contrast studies are not usually helpful and can make endoscopic procedures more difficult (i.e., white barium obscuring the view) and dangerous (i.e., risk of aspiration).

CT scan and ultrasonography may be indicated to evaluate liver disease with cirrhosis, cholecystitis with hemorrhage, pancreatitis with pseudocyst and hemorrhage, aortoenteric fistula, and other unusual causes of upper gastrointestinal hemorrhage.

Nuclear medicine scans may be useful to determine the area of active hemorrhage.

Nasogastric lavage

This procedure may confirm recent bleeding (coffee ground appearance), possible active bleeding (red blood in the aspirate that does not clear), or a lack of blood in the stomach (active bleeding less likely but does not exclude an upper gastrointestinal lesion).

A nasogastric tube is an important diagnostic tool, and tube placement can reduce the patient's need to vomit. Placement for diagnostic purposes is not contraindicated in patients with possible esophageal varices.

The characteristics of the nasogastric lavage fluid (e.g., red, coffee grounds, clear) and the stool (e.g., red, black, brown) can indicate the severity of the hemorrhage. Red blood with red stool is associated with an increased mortality rate from more active bleeding compared with negative aspirate findings with brown stool.

Acute Care/Hospitalization

Stabilize the patient with intravenous fluids (usually normal saline, except in patients with severe liver disease, ascites, or heart failure) and transfuse to maintain a hemoglobin level of 8-10 g. Promptly correct any abnormalities in coagulation. If the patient presents with active GI bleeding and impending cardiovascular shock (systolic blood pressure less than 100mm Hg), consider starting two 18 gauge or larger IV lines and starting with fluid resuscitation with 0.9 percent saline or lactated Ringer’s solution.

Aggressive resuscitation can reduce mortality in acute UGIB.

Medical Therapy

The use of H2-receptor antagonists has not been shown to be effective in altering the course of UGIB.

The efficacy of oral proton pump inhibitors (PPIs) remains controversial (one study with small numbers). Intravenous PPIs may improve the stability of the clot if the gastric pH can be kept above 6.2 (reducing fibrinolysis). This requires high-dose intravenous therapy: an intravenous bolus followed by continuous infusion for 48-72 hours. The primary problem is a perforated arterial (high pressure) vessel with a potential to rebleed; therefore, pharmacologic therapy should be used only after endoscopic therapy. This therapy has been shown to be cost-effective by Barkun et al (2004).

The goal of medical therapy is to correct shock and coagulation abnormalities and to stabilize the patient so that further evaluation and treatment can proceed.

Invasive Procedures

Consider endoscopy to be the main diagnostic modality in evaluating acute GI bleeding. Upper endoscopy allows visualization of the entire mucosal surface of the esophagus, stomach, and proximal duodenum. Endoscopy is the main procedure for diagnosis, tissue sampling, and treatment of active bleeding sites.

Consider surgery or angiographic therapy if the patient seems unstable or bleeding continues after initial resuscitation.
Complications

Be alert for possible aspiration of blood in the patient with hematemesis and an altered mental status.

For elderly or depressed patients, check medications carefully, as selective medications may pose an increased risk of GI bleeding.

Planning and implementation of care can be divided into two phases:

Emergency care: control the shock.

Definitive care: control the bleeding.

Prognosis

Expect most episodes of acute GI bleeding to stop without any intervention. However, the likelihood that a specific individual’s bleeding will stop is determined by the underlying cause and any comorbidity.

Nursing Diagnoses

Nursing diagnoses that may apply to the patient with an upper GI bleed include:

  • Fluid volume deficit
  • Impaired tissue integrity
  • Altered tissue perfusion
  • Impaired gas exchange
  • Sensory-perceptual alteration
  • Anxiety.

Patient Education

General Information

Ensure that your patient understands that an accurate diagnosis and appropriate management of the underlying disease are essential in preventing recurrent GI bleeding.

Educate patients about the signs and symptoms of recurrent GI bleeding, and about how to avoid medications that may increase the risk of GI bleeding.

Self-care Instructions

Ask your doctor before taking aspirin or other similar products.

If bleeding is related to alcohol use, carefully follow your doctor’s advice on and recommendations for stopping drinking.

If you have any new symptoms of blood loss, such as dizziness or weakness with standing, vomiting of blood or bloody or tarry stools, seek medical attention right away.

If you develop stomach pain, heartburn, or acid indigestion, contact your doctor; early treatment might prevent rebleeding.

Follow-up

Schedule regular appointments for patients who have had major GI bleeds. Monitor these patients with serial hematocrit and hemoglobin test tests to help guide therapy and to detect ongoing occult GI blood loss.

Now, let’s shift gears and talk about hemoptysis, which may be confused with hematemesis.

Hemoptysis

The word “hemoptysis” comes from the Greek “haima” for “blood” + “ptysis” meaning “a spitting” = a spitting of blood.

Hemoptysis can be defined as bloody expectoration from the larynx, trachea, bronchi and the lungs. One must, therefore, exclude bleeding from the nose mouth and pharynx, as well as hematemesis. Massive hemoptysis is defined as greater than 600 ml over a 24-hour period. In contrast to GI bleeding which is defined as greater than 6 units in a 24 hour period. The source of the blood is typically not in the upper tract (nasopharynx) but instead from the larynx, tracheobronchial tree, or alveoli. The amount of blood involved (unless massive) does not parallel the severity of the underlying cause.

Hemoptysis, particularly if it involves a large quantity of blood or is recurrent, is a frightening, potentially fatal event, requiring an immediate search for the cause and the precise location of the bleeding. Patients will commonly describe a feeling of something in their throat following with the abrupt expectoration of blood. Even with amounts as small as 150 ml, asphyxiation is a risk when the patient is unable to clear secretions.

Hemoptysis must be differentiated from hematemesis and from blood dripping into the tracheobronchial passages from the nose, mouth or nasopharynx. The patient may be able to sense and to tell the examiner where the bleeding originated, even specifying which side of the chest. History, physical examination, chest X-rays, and bronchoscopy are the most important diagnostic steps.

Bleeding time, clotting time, platelet count, prothrombin time, and partial thromboplastin time should be determined immediately to discover any clotting abnormalities. Drugs that adversely affect clotting, such as aspirin, should be stopped. Stopping the bleeding requires an approach related to the cause. Bleeding from a major vessel may require lung resection or ligation of the bleeding vessel, but because these have a high mortality risk, they are appropriate only as a last resort.

Allaying fear is the most difficult task for the doctor and the nurse, and staying calm is especially hard for the patient and his or her family. The almost constant presence of a sympathetic and reassuring therapist is usually the most calming measure.

Hemoptysis is the expectoration of blood from the respiratory tract, in amounts ranging from streaks of blood mixed with sputum to cups of blood mixed with sputum to cups of frank blood. Although blood from the gastrointestinal or upper respiratory tract can be coughed up, hemoptysis most accurately describes bleeding originating in the lower respiratory tract.

When caring for a patient who complains of coughing up blood, it is important to assess the quantity of blood loss. Massive hemoptysis is variably defined as expectoration of greater than or equal to 100 ml to 600 ml of blood in a 24-hour period, is a life-threatening event, and usually warrants admission to an intensive care unit. In cases of massive hemoptysis, evaluating physicians must ensure hemodynamic stability, protect the airway and maintain its patency, and protect the non-bleeding lung from drowning in blood.

When rust-colored or red sputum is present, the nurse is concerned about the presence of hemoptysis, a sign of infection, but hemoptysis is also present in cancer, heart failure, and pulmonary infarction. When evaluating the sputum for hemoptysis, the nurse must remember that old blood appears dark brown or dark red, and fresh blood is bright red. Because patients tend to exaggerate when hemoptysis is present, the nurse, doctor or laboratory should save all hemoptysis in a cup or basin for examination. Vigorous coughing, chest trauma, chest physical therapy, anticoagulant therapy, and activity may aggravate hemoptysis. True hemoptysis must be differentiated from hematemesis (vomiting blood) and epistaxis (bleeding from the nares). Hemoptysis comes from the lung, but hematemesis and epistaxis do not. Blood draining posteriorly from the nose may elicit coughing and or vomiting of blood. Sometimes it is difficult to tell from the patient’s description the origin of the blood.

Patients who have less severe hemoptysis should be evaluated expediently to identify the source of bleeding. A detailed history is invaluable for directing the diagnostic work-up. Primary care physicians must be able to recognize significant and life-threatening cases of hemoptysis to ensure the patients are observed and treated in the appropriate setting. Likewise, these same clinicians must recognize that “coughed up blood” may actually arise from the upper respiratory or gastrointestinal tracts. The majority of the hemoptysis cases seen by the primary care physician results from acute bronchitis in which the blood loss is less than 100 ml.

Initial treatment involves placing the patient in a semi-recumbent position with the bleeding side down (where possible) to prevent aspiration of blood into the good lung. Antibiotics for an exacerbation of bronchitis are usually prescribed. Narcotics for cough suppression may reduce the severity and frequency of the cough which is traumatic to the airway by itself. Complete sedation is not desirable.

Sedation, anesthesia, and intubation to protect the airway interfere with the patient's own ability to expectorate the blood and are not considered a first line therapy. Once these measures are chosen the healthcare provider assumes responsibility for maintaining an open airway; a challenging task.

The timing of a bronchoscopic examination is controversial. Fiber-optic bronchoscopy with a two to 3 mm suction channel may be inadequate for maintaining a patent airway. Diagnostic bronchoscopy is best deferred until bleeding is tapering away, allowing the endoscopist to perform a complete diagnostic exam and to trace the bleeding to its point of origin. Predictions about the site of bleeding are fraught with hazard. A convincing localization of a bleeding site consists of the observation of active bleeding followed by clearing with suction, followed by observation of the return of bleeding from the same site. Dependent segments are prone to accumulate aspirated blood and identification of dependent segments as a bleeding site must be very carefully assessed. Rigid bronchoscopy allows for suction and tamponade of larger quantities of bleeding and may be used and an acute situation. No one should underestimate the difficulty of completing an examination under these trying circumstances when asphyxia remains and ever present hazard.

Causes of hemoptysis

  • Inflammatory
  • TB
  • Bronchitis
  • Bronchiectasis
  • Lung abscess
  • Pneumonia
  • Neoplastic
  • Bronchial carcinoma
  • Bronchial adenoma
  • Hemangioma
  • Others
  • Pulmonary hypertension
  • Left ventricular failure
  • Recurrent pulmonary thrombo-emboli
  • AV malformations
  • Pulmonary vasculitis --
  • Alveolar hemorrhage
  • Goodpasture’s syndrome (anti-glomerular basement antibody disease)

Stabilization of the patient with transfusions and other treatment is essential before or during diagnostic evaluation. All patients require a complete history and physical examination; blood studies, including coagulation studies -- platelet count, prothrombin time, partial thromboplastin time; and liver function tests -- bilirubin, alkaline phosphatase, albumin, AST, ALT, with repeated monitoring of Hb and Hct.

History

There is no substitute for a detailed history in cases of hemoptysis. Ask about pulmonary symptoms, non-pulmonary symptoms of underlying disease, medical history, medications, social history (smoking, drug use) and family history. Remember that quantity of blood loss is important, but cannot reliably predict the cause of hemoptysis.

Ask about non-pulmonary symptoms that might provide clues to the etiology of hemoptysis, such as lower extremity edema, hematuria, skin rash or joint pain.

Ask about exposures in the workplace.

Ask about legal and illegal drug use, family history of easy bruising or bleeding, hemoptysis or GI bleeding, and travel history.

Assess smoking history and risks for lung cancer.

Ask about painful urination, especially a burning sensation.

Physical Examination

Before proceeding to a through physical exam, obtain vital signs and assess for an orthostatic blood pressure, and observe the patient for signs of airway compromise (dyspnea, respiratory distress, stridor wheezing, or cyanosis).

When the patient is clinically stable, perform a through examination to discern the etiology of hemoptysis. Rule out an ear-nose-and-throat (ENT) or GI source of bleeding.

Medical Therapy

Treat the basic cause. The hemoptysis generally will stop spontaneously and no treatment apart from reassurance is needed.

Keep the patient calm.

Require complete bed rest.

Suppress the cough if it is troublesome and aggravating the hemoptysis.

First ,achieve stoppage of the bleeding -- then do the other investigations -- especially the invasive respiratory investigations.

For patients with blood-streaked sputum, a normal chest X-ray, a typical history of bronchitis, and no risk factors for lung cancer for bronchitis, follow up once the symptoms resolve or if the symptoms do not resolve as expected.

Observe the patient with mild hemoptysis; some might not need any treatment.

Treat the underlying disease.

Use antitussives to suppress but not obliterate the cough in the acute setting.

Acute Hospitalization

Admit all patients with massive hemoptysis to the hospital. Intensive care monitoring and early consultation with a specialty service, such as pulmonary medicine and thoracic surgery, are indicated in every case.

In a patient with massive hemoptysis that is refractory to other treatments, consider surgical resection.

Provide bed rest and partial cough suppression with narcotics to decrease or stop the bleeding.

Use endotracheal intubation to maintain airway patency and adequate oxygenation.

Management Highlights

Evaluate the patient’s mental status, and check the supine and standing blood pressures and heart rate to assess hemodynamic stability.

Based on the patient’s history, try to localize the site of bleeding to the upper or lower respiratory tract or to the gastrointestinal tract.

If the patient has blood-streaked sputum and manifestations of acute bronchitis (recent onset productive cough, fever, malaise), consider outpatient management for acute bronchitis.

If the estimated amount of bleeding is greater than 100 ml/24 hours, hospitalize the patient and consider admission to the intensive care unit for monitoring.

General Advice

Always take hemoptysis seriously, and evaluate patients in a timely manner.]

Patient Education

Self-Care Instructions

Contact your doctor whenever you cough up blood.

Remember that each episode of coughing up blood is unpredictable, and the next episode may be much more difficult to control than any previous episodes.

If you are worried about the quantity of blood coughed up and are unable to contact your doctor right away, go to the local emergency room.

Ask your doctor about when it is safe to use aspirin and other non-steroidal anti-inflammatory medications, alcohol, and herbal preparations.

If no cause is found and malignancy or systemic disease is not suspected, instruct the patient to return in two to four weeks to be reevaluated.

Prevention & Screening

There is not a specific screening test for hemoptysis; instead, promote prevention by recognizing and treating potential hemoptysis-associated diseases.

Conclusion

Remember that your first priority in treating a patient with either hematemesis or hemoptysis is to maintain the airway, control the bleeding and maintain the hemodynamic status. Once stabilization of the patient is accomplished, diagnostic and therapeutic interventions can be properly performed.

Sharon Lesser, RN, is a pulmonary clinical nurse II in the department of pulmonary and critical care medicine at the University of Maryland Hospital in Baltimore, Md.


References

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  3. Gong H, Salvatierra C. Clinical efficacy of early and delayed fiberoptic bronchoscopy in patiens with hemoptysis. Am Res Respir Dis. 1981; 124:221-5.
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  5. Peacock and Lovett Clinicopathological Conference: Massive Hematemesis Following Blunt Abdominal Trauma Acad Emerg Med.2003; 10: 1086-1095
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