Which assessment should the nurse perform first for a patient who just vomited bright red blood?

Something you’ll see pretty regularly if you work on a medical unit or emergency room is the gastrointestinal bleed. GI bleeds come in many forms…the slow steady bleed that sneaks up on the patient and they don’t even know they’re sick until they’re hemoglobin drops so low that they can’t catch their breath or stand up unassisted. Then there’s the coffee-ground emesis type of bleed, the bright red “oh-my-gosh-what-is-that-in-the-commode” type of bleed and the oh-so-scary upper GI bleed from a fragile esophagus. But before we get into all that, let’s start with the basics.

Upper vs lower GI bleeds

You will often hear GI bleeds referred to by their location of origin…upper or lower. When we talk about upper GI bleeds, we are talking about bleeds that originate above the duodenum; lower GI bleeds are below the duodenum (and if you forgot, the duodenum is the first segment of the small intestine).

Coffee, tar or frank?

The blood from your patient’s GI bleed will typically present in one of three forms:

Coffee-ground emesis: this is the result of partially-digested or clotted blood (ewwwww) in the upper GI tract. Typically if the blood looks like coffee grounds, this means it’s been in there for a bit so there’s a chance the bleeding is not likely happening right now.

Black, tarry stools (also known as “melena”): if your patient has black tarry stools, this means that bleeding is taking place in the esophagus, stomach or the upper part of the small intestine. Melena has a distinctive odor that you will never, ever, ever forget.

Frank bleeding: bright red blood (also called “frank bleeding”) is a sign that bleeding is occurring RIGHT NOW and can be from the upper or lower GI tract. In the lower GI tract, this could be due to diverticulosis, anal fissures, hemorrhoids, inflammatory bowel disease or even cancer. When there’s bright, frank blood passing through the anus it’s called “hematochezia.” In the upper GI tract it’s typically because of a baaaad ulcer or problems in the esophagus…tears, varices, cancer or severe esophagitis.

Whatcha gonna do about it?

I always say that nursing is all about seeing problems and fixing them…so how do you intervene when your patient has a GI bleed?

Assessments

• Serial H/H (typically q 4 or q 6 hours)
• Monitor PLTs, INR, PTT
• Watch for signs of bleeding
• Monitor BP and check for orthostatic hypotension
• Perform occult blood test on stool
• Assess abdominal pain

Interventions

• Ensure two IVs in place for blood administration, fluids, antibiotics (if needed), electrolyte replacement, protonix gtt, etc…
• Make sure pt’s type & screen is current; transfuse as necessary
• Prep patient for endoscopy (either EGD or colonoscopy)
• Prep patient for interventional radiology if problem can’t be treated by traditional endoscopy
• Anticipate patient being NPO initially, then clears, then advance as tolerated
• Administer medications such as protonix, antifungals and antibiotics as needed
• Replace fluids and electrolytes
• Anticipate many many trips to the bedside commode (or many many clean-up projects). Blood in the GI tract is very irritating, which leads to increased gastric motility.

When GI bleeds go bad

If the bleed is bad enough then your patient can bleed out right in front of you. To me, the scariest GI bleeds are from Mallory-Weiss tears or esophageal varices. These esophageal hemorrhages are devastating and often very rapidly fatal. Have suction ready at the bedside at all times and be extra watchful for any increase in bloody emesis.

Patients can bleed out via the rectum as well, so ANY increase in bleeding, significant drop in hemoglobin or blood pressure should be immediately investigated and reported!

Looking for even more information about the gastrointestinal system? Check out Med Surg Starter Pack study guides!

Be safe out there!

You should call an ambulance or go directly to the nearest emergency department if you bring up (vomit) blood. Often the bleeding will stop quite quickly but in some cases it can become severe and life-threatening. So always play safe and seek medical help quickly. There is a range of different causes - discussed below. Many causes can be treated but the first priority is to make sure the bleeding stops. The rest of this leaflet aims to give some background information but is not a substitute for obtaining immediate medical attention if you vomit blood.

What is vomiting blood (haematemesis)?

The medical word for vomiting blood (or throwing up blood) is haematemesis. This symptom is usually due to 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.

Vomiting of blood is a medical emergency. In many cases the bleeding will stop quite quickly but in some cases it can become severe and life-threatening. Therefore, call an ambulance or go directly to the nearest emergency department if you vomit blood.

Understanding the upper gut

Your gut (gastrointestinal tract) is the tube that starts at your mouth, and ends at your bottom (anus).

The upper gut includes the gullet (oesophagus), stomach and first part of the gut (small intestine) known as the duodenum. Food passes down the gullet into the stomach. The stomach makes acid which is not essential but helps to digest food. After being mixed in the stomach, food passes into the duodenum, to be digested.

Some 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 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.

Other symptoms may occur at the same time as vomiting blood. For example, tummy (abdominal) pain, high temperature (fever), feeling unwell, or other gut symptoms. If you lose a lot of blood, it can make you feel dizzy or even pass out. 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 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.
• Swallowing 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.
• 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.

What tests may be needed?

A doctor's assessment

Your doctor is likely to ask various questions about the nature of the bleeding and ask if you have any other symptoms. He or she will also examine you.

The doctor will 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 doctor 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. A thin, flexible 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.

What is the 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 the bleeding is severe. 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, an initial treatment to stop any ongoing 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.