Hematemesis (OSCE)

DDx

• peptic ulcer disease
• gastritis/gastropathy (NSAID, alcohol, stress related)
• Mallory-Weiss tear
• variceal rupture
• erosive esophagitis
• foreign object
• vascular malformations (Dieulafoy’s lesion, AVMs, aorto-enteric fistula)
• neoplastic disease (esophageal or gastric)
• other
  • systemic bleeding disorder
  • epistaxis
  • hemoptysis

ABCs

• hematemesis can be life threatening

Patient ID, CC

Vomiting

• onset
• precipitant (coughing, forceful vomiting)
• frequency
• characteristics (dry retching and strenuous, protracted)

Vomitus

• volume
• color (bright red, dark red, black)
• properties (coffee grounds - specks of congealed blood, pure blood, mixed with stomach contents)

Accompanying symptoms

• non GI source → epistaxis, hemoptysis, bleeding in gums/mouth, bruising, petechiae
• gastritis → GERD
• Mallory Weiss tear → strenuous or protracted vomiting
• PUD → dysphagia, odynophagia, retrosternal/epigastric discomfort
• varices → jaundice, ascites, generalized edema
• melena → bleeding > 12 hour old
• Anemia (ominous signs)
  • orthostatic lightheadedness, dyspnea, fatigue, edema
  • pallor, headache

Medications

• NSAID, ASA
• anticoagulants: warfarin, heparin, clopidegrel

PMHx

• prior episodes (diagnosis and outcome)
• PUD → smoking and EtOH
• neoplasm, malnutrition, stress ulcers → systemic illness, recent weight loss, major surgery