Vomiting Blood (Hematemesis)

What to do right now

1. Call 911 or your local emergency number if you have vomited more than a small amount of blood, or feel faint, dizzy or weak.
2. Lie on your side if you feel faint, to prevent choking if you vomit again.
3. Do not eat or drink in case you need an endoscopy.
4. Do not take aspirin, ibuprofen or other NSAIDs.
5. Note how much blood, its color, when it started, and whether stools are black.
6. Bring a list of your medicines, especially blood thinners, aspirin, NSAIDs and steroids.

Is it really blood from the stomach?

Blood in vomit can come from other places:

• Nose or mouth: blood from a nosebleed, dental work or a cut in the mouth can be swallowed and then vomited.
• Lungs: coughing up blood (hemoptysis) is frothy and bright red, mixed with sputum, and follows coughing rather than vomiting.
• Food and drink: red wine, beets, tomato, red gelatin or drinks can look like blood. Black iron tablets and bismuth can darken vomit or stools.

Causes of vomiting blood

Peptic ulcers

A peptic ulcer in the stomach or duodenum is the most common cause. Ulcers are mainly caused by Helicobacter pylori infection and by NSAIDs such as ibuprofen, naproxen and aspirin. Some people have burning upper abdominal pain beforehand; others have no warning at all, especially older adults on NSAIDs.

Gastritis and esophagitis

Inflammation of the stomach lining (gastritis) or esophagus (esophagitis) can ooze blood. Triggers include alcohol, NSAIDs, severe illness and acid reflux.

Mallory-Weiss tear

A tear at the junction of the esophagus and stomach caused by forceful vomiting or retching, often after heavy drinking or a stomach bug. Typically, the first vomits contain no blood, then blood appears. Most stop bleeding on their own, but they still need assessment.

Esophageal varices

In people with cirrhosis and other liver disease, high pressure in the portal vein causes swollen veins in the esophagus. Varices can rupture and cause massive, life-threatening bleeding. Anyone with known liver disease who vomits blood needs emergency care immediately.

Other causes

• Stomach cancer and esophageal cancer: often with weight loss, difficulty swallowing and persistent indigestion.
• Blood thinners and clotting problems: make any bleeding source bleed more.
• Swallowed foreign objects or caustic substances.
• Vascular malformations in the stomach lining.
• Boerhaave syndrome: a full rupture of the esophagus after violent vomiting, with severe chest pain; rare and very serious.

How it is diagnosed

In the ER, doctors first check pulse, blood pressure and signs of shock, and start IV fluids. They then:

• take blood tests: blood count (hemoglobin), clotting, kidney and liver function, and blood type and crossmatch for transfusion
• ask about ulcers, liver disease, alcohol, NSAIDs, blood thinners and previous bleeding
• use risk scores, such as the Glasgow-Blatchford score, to decide how urgently endoscopy is needed and whether some low-risk patients can be managed as outpatients
• perform an upper endoscopy, a flexible camera passed through the mouth, usually within 24 hours. It finds the source and allows treatment at the same time

A CT angiogram may be used if bleeding is heavy and endoscopy does not find the source.

Treatment

• Resuscitation: IV fluids and blood transfusion if needed.
• Acid suppression: IV proton pump inhibitors (PPIs) help ulcers stop bleeding and heal.
• Endoscopic treatment: injecting medicine, clipping or cauterizing a bleeding ulcer; placing bands around bleeding varices.
• For varices: medicines that lower portal pressure (such as octreotide) and antibiotics, which reduce infection and rebleeding in cirrhosis. A TIPS procedure is used for bleeding that continues.
• Reversing blood thinners where appropriate.
• Surgery or interventional radiology if bleeding cannot be stopped by endoscopy.

After the bleed, ulcer patients are tested and treated for H. pylori, and NSAIDs are stopped or protected with a PPI.

Preventing another bleed

• Avoid NSAIDs if you have had an ulcer, or take them only with a PPI on a doctor's advice.
• Complete H. pylori treatment and confirm it has been cleared.
• Limit or stop alcohol.
• People with cirrhosis should be screened for varices and treated to prevent bleeding.

Frequently asked questions

Is vomiting blood an emergency?

Yes, in most cases. Vomiting more than a few streaks of blood, or any blood with dizziness, fainting, black stools or known liver disease, needs emergency care. Even if bleeding seems to stop, it can restart, so get assessed promptly.

What does coffee-ground vomit mean?

Coffee-ground vomit is dark brown or black, grainy material. It is blood that has been partially digested by stomach acid, which usually means slower bleeding from the stomach or duodenum, often from an ulcer or gastritis. It still needs urgent medical assessment.

Why did I vomit blood after drinking alcohol?

Heavy drinking can inflame the stomach lining, and forceful vomiting can tear the lining where the esophagus meets the stomach (a Mallory-Weiss tear). In people with alcohol-related liver disease, it can mean bleeding varices, which is life-threatening. Get checked the same day.

Can stress cause you to vomit blood?

Stress alone does not usually cause vomiting blood. Severe physical stress, such as major illness or surgery, can cause stress ulcers. Emotional stress may worsen indigestion, but vomiting blood always needs a medical cause looked for.

Can a small amount of blood in vomit be normal?

A small streak after violent retching, or blood swallowed from a nosebleed, can be minor. But it is hard to judge the source and amount at home. If you are unsure, or it happens more than once, get medical advice the same day.