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

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