Hematemesis

　　Hematemesis (hematemesis) refers to the vomiting of blood by patients, caused by acute bleeding in the upper gastrointestinal tract (esophagus, stomach, duodenum, jejunum after gastrojejunal anastomosis, pancreas, biliary tract). It can also occur in certain systemic diseases. Before determining hematemesis, it is necessary to exclude bleeding from the oral cavity, nose, pharynx, and other parts as well as hemoptysis. What are the causes of hematemesis? The following experts introduce the causes of hematemesis.

　　1, Pseudohematemesis and hematochezia are seen in the following situations:

　　(1) Swallowing maternal blood: Infants may swallow maternal birth canal blood or inhale breast milk from the head during delivery, and an Apt test can be used to distinguish maternal blood from the newborn's own blood.

　　(2) Blood from the mouth and nose injury bleeding into the digestive tract.

　　2, Neonatal hemorrhagic disease Neonatal hemorrhagic disease is caused by vitamin K deficiency. Hematemesis and hematochezia usually appear 2-3 days after birth, and in severe cases, bleeding in other parts can occur due to late-onset vitamin K deficiency. Hematemesis and hematochezia can also occur.

　　3, Other less common systemic hemorrhagic diseases, such as DIC neonatal thrombocytopenic purpura and various congenital coagulation factor deficiencies, etc.

　　4, Gastrointestinal diseases:

　　(1) Reflux esophagitis: Clinical manifestations include intractable vomiting, which may be accompanied by hematemesis or hematochezia. Hematemesis and hematochezia in newborns are often accompanied by malnutrition and poor growth and development.

　　(2) Stress ulcer: Stress ulcer and gastrointestinal bleeding can occur in hypoxia, intracranial hypertension, and severe infection.

　　(3) Acute gastroenteritis: Most acute gastrointestinal inflammation caused by pathogens, in addition to fever, vomiting, and diarrhea, severe cases can also present with hematochezia and hematemesis.

　　(4) Intestinal obstruction: Clinical manifestations include vomiting, abdominal distension, hematemesis, or hematochezia.

　　(5) Diseases of the sigmoid colon, rectum, and anus: mostly polyps, anal rectal fistula, and anal fissure cause hematochezia.

　　A series of systemic symptoms can be caused by massive hematemesis, and hemorrhagic anemia and (or) hemorrhagic shock can occur when the blood loss exceeds more than 1/5 of the total blood volume. Hemorrhagic shock caused by massive blood loss is called hemorrhagic shock (hemorrhagic shock), which is common in bleeding caused by trauma, peptic ulcer bleeding, esophageal variceal rupture, and bleeding caused by gynecological and obstetric diseases. Whether a shock occurs after bleeding not only depends on the amount of bleeding but also on the speed of bleeding. Shock often occurs when there is rapid and massive (more than 30-35% of the total blood volume) bleeding without timely supplementation.

　　Children with acute hemorrhagic shock have not yet presented with hematemesis and melena, but they already have general weakness, weak crying, pale mucous membranes, a rapid heart rate and weak heart sounds, blood pressure drop, and signs of shock, and have ruled out causes such as infection, central nervous system injury, respiratory distress, and heart failure, then consider the possibility of acute hemorrhagic shock, and observe whether there is gastrointestinal bleeding.

　　What are the typical symptoms of hematemesis? Hematemesis refers to the vomiting of blood due to acute bleeding in the upper gastrointestinal tract (esophagus, stomach, duodenum, jejunum after gastrojejunal anastomosis, pancreas, biliary tract). It can also be seen in certain systemic diseases. Then, what symptoms may hematemesis have? The following experts introduce the clinical manifestations of hematemesis.

　　1. Pseudo-hematemesis and/or melena

　　(1) Swallowing maternal blood: Neonates taking iron, bismuth preparations, phenolphthalein, or traditional Chinese medicine can cause pseudo-gastrointestinal bleeding, but it is rare. Swallowing maternal blood from the birth canal during delivery, or inhaling maternal blood from cracked or eroded nipples, can cause neonatal pseudo-hematemesis and/or melena, which is more common. Children generally have good general condition, no anemia or hemorrhagic shock, and the alkali-resistant hemoglobin test (Apt test) can clearly identify the blood as maternal blood.

　　(2) Swallowing one's own blood: Neonates can also cause hematemesis and/or melena by swallowing blood from their own nasopharynx or airway, which needs to be differentiated from true gastrointestinal bleeding. Usually, there is a history of intubation or other trauma and local injury or bleeding. There may be black tarry stools, and the moist part of the diaper at the edge of the stool (if not wet, add water) may have blood-streaked occult blood or positive red blood cells under microscopic examination.

　　2. Systemic hemostatic and thrombotic diseases have manifestations of extraintestinal bleeding, such as skin and subcutaneous hemorrhagic spots and ecchymoses, and there are abnormal changes in the coagulation and anticoagulation tests. Among them, DIC in critically ill children is the most common. DIC patients may present with severe infection, hardening of the skin, or RDS, and congenital alloimmune or passive immune thrombocytopenic purpura or various congenital coagulation factor deficiencies are less common, often with a positive family history and corresponding abnormalities in coagulation and anticoagulation. In the neonatal period, the most common disease of this kind is neonatal hemorrhagic disease. Neonatal hemorrhagic disease often appears between 2-6 days after birth, with hematemesis, the amount of blood is usually more, and the vomitus is mostly fresh blood without other components.

　　Neonates with hematemesis and melena, children generally in good condition. Delayed vitamin K deficiency syndrome is common in neonates who have been on long-term parenteral nutrition with antibiotics or infants breastfed by mothers with poor dietary habits. Vitamin K 15-10mg is administered intravenously or intramuscularly upon discovery of bleeding, and fresh whole blood or frozen plasma can be transfused to achieve hemostasis.

　　3. Gastrointestinal bleeding diseases

　　(1) Gastroesophageal reflux disease: Symptoms include vomiting, hematemesis, and weight gain slowing down, or no symptoms at all. Endoscopy and barium meal examination can detect superficial lesions, and a pH value persistently below 5.0 has diagnostic value. Local hemostasis can be performed by electrocautery.

　　(2) Stress ulcer: Neonatal stress ulcer is very common, with hypergastrinemia that can last up to the 10th day after birth, especially the first 2 to 4 days. Increased intracranial pressure can also cause stress ulcer. It often occurs in the early neonatal period with hematemesis and melena, with varying amounts of blood and old and new blood. Conservative medical treatment can cure it. Ulcers can also be seen in the esophagus or duodenum at the same time.

　　(3) Acute gastroenteritis: It can have hematemesis and/or melena, especially necrotizing enterocolitis (NEC) which is more common in premature infants, which is more serious. Children with acute gastroenteritis have common symptoms such as fever, weakness, vomiting, and diarrhea. Stool is mucous with blood, fresh stool, jam-like stool, or black stool. Fresh blood or coffee-colored brown blood is often associated with allergic enteritis caused by milk or other protein foods, which can also have hematemesis and/or melena, but it is less common. Stopping this type of protein food can alleviate the symptoms.

　　(4) Intestinal obstruction: The main cause of lower gastrointestinal bleeding in newborns is intestinal obstruction, including paralytic and/or mechanical intestinal obstruction caused by various medical and surgical diseases, but mainly by internal medical diseases. The children have poor nutrition and development, and severe vomiting can cause gastrointestinal bleeding.

　　(5) Diseases of the anal, rectal, and sigmoid colon: Most are blood in stool rather than black tarry stool. Most have severe constipation, polyps, and anal-rectal fissures as causes.

　　4. Systemic symptoms in addition to hematemesis and the aforementioned manifestations can also be caused by massive blood loss, which can lead to a series of systemic symptoms. When the blood loss exceeds more than 1/5 of the total blood volume, it can manifest as anemia due to blood loss and/or shock due to blood loss. Clinical symptoms include rapid heart rate, cyanosis of the extremities, chills, blood pressure drop, skin discoloration, lassitude, and alternating between irritability.

　　Hematemesis refers to the vomiting of blood by patients, which is caused by acute bleeding in the upper gastrointestinal tract. It can also occur in certain systemic diseases. Before determining hematemesis, it is necessary to exclude bleeding from the oral cavity, nose, throat, and other parts, as well as hemoptysis. Prevention is better than treatment, so how to prevent hematemesis? The following experts introduce the preventive measures for hematemesis.

　　1. Actively prevent and treat primary diseases: Hematemesis is a complication caused by various gastrointestinal diseases. Treating the primary disease can effectively prevent the occurrence of upper gastrointestinal bleeding.

　　2. Avoid extreme emotional stress: Strong emotional trauma, emotional excitement, excessive worry and overthinking can trigger hematemesis. It is important to maintain emotional stability and a positive spirit. Properly handle various contradictions in daily work and life, and establish a relaxed, harmonious, and friendly neighborhood atmosphere.

　　3. Pay attention to the combination of work and rest: Overwork and insufficient sleep can cause disorders of the autonomic nervous system, promote self-digestion of the gastric juice by the gastric mucosa, and cause inflammation, ulcers, and bleeding of the gastric mucosa. Therefore, life should be regular, avoid overwork, and ensure adequate sleep.

　　4. Pay attention to diet adjustment: Irregular diet, abnormal hunger and satiety, unbalanced cold and hot, or overeating of fatty, spicy, smoked, fried, and cold foods, over time can damage the defensive function of the gastric mucosa, causing changes in the gastric mucosa. The distribution of three meals a day should be reasonable, fresh and clean, light and easy to digest. Increase protein and vitamins appropriately. Drinking can cause the gastric mucosa to become congested, edematous, and eroded, and can also cause vitamin deficiency, decreased coagulation factors, increased vascular fragility, leading to bleeding. Nicotine in tobacco has a strong harmful stimulatory effect on the gastric mucosa, causing bile reflux, damage to the mucosa of the digestive tract, inflammation, erosion, ulcers, and bleeding. It is necessary to quit smoking and drinking absolutely.

　　5. Strengthen physical exercise: Weak physique and low resistance of the digestive tract are the most fundamental cause of upper gastrointestinal bleeding. The fundamental method to effectively prevent the occurrence of upper gastrointestinal bleeding is to enhance physical fitness and improve the body's resistance.

　　6. To prevent spontaneous bleeding in newborns, pregnant women can take vitamin K orally before delivery; newborns with difficult labor, premature birth, or digestive tract malformations should be injected with vitamin K after birth. Actively treat infectious diseases and prevent the occurrence of DIC, stress ulcer, acute gastroenteritis, and other diseases.

　　Vomiting blood refers to the vomiting of blood by the patient, which is caused by acute bleeding from the upper gastrointestinal tract (esophagus, stomach, duodenum, jejunum after gastrojejunal anastomosis, pancreas, biliary tract). However, it can also be seen in certain systemic diseases. So, what kind of laboratory tests are needed for the diagnosis of hematemesis? The following experts introduce the examination items required for hematemesis.

　　One, laboratory examination:

　　1. Routine examination includes blood routine, platelets, coagulation time, thromboplastin time, and other general examinations. In systemic coagulation diseases, there are abnormal changes in the coagulation and hemostasis tests, such as DIC or vitamin K deficiency syndrome. Congenital alloimmune or passive immune thrombocytopenic purpura or various congenital coagulation factor deficiencies may also lead to abnormal coagulation and hemostasis.

　　2. Fecal examination shows red blood cells, and the occult blood test is strongly positive. Children with acute gastroenteritis may have mucous blood stools, fresh blood stools, and so on.

　　3. The Apt test is used to distinguish between maternal blood and newborn's own blood. Blood samples from the infant's vomit or feces are mixed with five times the amount of water, stirred well, and then centrifuged at a speed of 2000 rpm for 2 minutes. The pink supernatant (5 portions) is transferred to test tubes, and 1% sodium hydroxide (1 portion) is added. After 2 minutes, observe the results. If the reagent changes from pink to brownish yellow, it indicates adult hemoglobin (HbA), suggesting that the blood is from the mother. If the test remains pink, the blood comes from the newborn. The blood swallowed by the newborn from their own nasopharynx or airway is mainly fetal hemoglobin (HbF).

　　II. Other auxiliary examinations:

　　1. Endoscopy

　　(1) Fiberoptic esophagogastroduodenoscopy: It is superior to barium meal X-ray, with a diagnostic rate of 75% to 90%, while the latter can only determine bleeding above or below the Treitz ligament at 50%. It can see the source of bleeding (positive rate 77%) and specific bleeding conditions, perform biopsy and hemostasis under direct vision, and observe superficial and minor changes that are not easily discovered by X-ray examination. It can also be examined during acute hemorrhage. Infants use GIF-P2 or GIF-P3 type scopes under general anesthesia or local anesthesia with diazepam and atropine. Before endoscopy, it is necessary to correct coagulation disorders and unstable hemodynamics, keep the airway open, and use antibiotics to prevent infection.

　　(2) Fiberoptic rectoscopy and colonoscopy: Rectoscopy is performed first before colonoscopy. A barium enema examination is generally done before colonoscopy, which is different from upper gastrointestinal endoscopy. Use PCF (Olympus) or FC-34MA type endoscope, and small-bowel endoscopy can be used instead of a small-bore gastroscope for infants.

　　2. X-ray examination

　　(1) Abdominal X-ray: Abdominal X-rays taken in supine, standing, or lateral positions can exclude intestinal obstruction and perforation. It is particularly important for neonatal small intestinal volvulus necrotizing enteritis and meconium peritonitis.

　　(2) Barium enema: Barium meal in the non-acute hemorrhage period has certain value for contrast. It is often added with methylcellulose for double-layer contrast. Barium enema can also be performed after inserting a tube into the duodenum for small bowel contrast examination (with or without methylcellulose). Barium enema is often helpful for the diagnosis of intussusception.

　　3. Radionuclide scanning is an effective and accurate examination method. Using 99mTc-sulfide or other technetium salts labeled red blood cells for scanning is most valuable for subacute or intermittent hemorrhage. The false positive rate reaches 15%, while the false negative rate reaches 25%.

　　4. Angiography is used for checking bleeding cases with a flow rate above 1.5-2.0 ml/min. For cases with large bleeding that cannot be operated on, embolization method can be tried to stop bleeding. However, due to the above-mentioned more advanced and non-invasive examination methods, this method is rarely used at present.

　　Hematemesis patients should pay attention to diet adjustment, as irregular diet, improper hunger and satiety, imbalance of cold and heat, or excessive intake of fatty, spicy, smoked, fried, and cold foods, may damage the defensive function of the gastric mucosa over time, causing lesions in the gastric mucosa. The distribution of meals should be reasonable, fresh and clean, light, and easy to digest. Increase the intake of protein and vitamins appropriately. Drinking can cause the gastric mucosa to become congested, edematous, and eroded, and can also lead to vitamin deficiency, decreased coagulation factors, increased vascular fragility, and bleeding. Nicotine in tobacco has a strong harmful stimulatory effect on the gastric mucosa, causing bile reflux, damage to the mucosa of the digestive tract, inflammation, erosion, ulceration, and bleeding. It is necessary to strictly quit smoking and drinking.

　　When hematemesis encounters gastrointestinal bleeding, especially in patients with massive bleeding, while actively analyzing and judging the possible causes of the disease, treatment should be given at the same time to prevent the patient from developing shock or further deterioration of shock, which may endanger life. The treatment includes general treatment measures, active replenishment of blood volume, and increased application of hemostatic drugs.

　　1. General treatment measures should include bed rest, for those with low blood pressure, they should lie flat with the head raised to keep the respiratory tract unobstructed. Hematemesis patients should avoid blood aspiration into the trachea to prevent asphyxiation. Patients with shock or elderly patients should be given oxygen, and those with hematemesis or large blood loss or considered to have variceal bleeding from the esophagus should be fasting. If necessary, a gastric tube can be inserted to monitor bleeding, and vital signs such as pulse, heart rate, respiration, blood pressure, and consciousness should be closely monitored. For those with shock, urine output should also be observed.

　　2. Actively replenish blood volume, first by infusing dextran 40 (low molecular weight dextran) or plasma substitutes, as well as isotonic saline and glucose solutions, for those with excessive blood loss or who have shown signs of shock, with the consent of the patient's family, active transfusion of whole blood should be carried out to replenish blood volume. For patients with liver cirrhosis, fresh blood should be transfused to prevent ammonia intoxication.

　　3. Application of Hemostatic Drugs

　　Mainly include H2 receptor antagonists and proton pump inhibitors, the former includes cimetidine, ranitidine, famotidine, etc., and the latter includes omeprazole, lansoprazole, pantoprazole, esomeprazole (esomeprazole), and rabeprazole, etc. When treating massive bleeding, it is generally adopted to use preparations that can be administered intravenously, and satisfactory hemostatic effects can often be achieved after the appropriate dosage of acid-suppressing drugs has been applied for peptic ulcers and bleeding caused by acute gastric mucosal lesions. It is generally believed that only when the intragastric pH reaches 6 or above is it conducive to inducing platelets to aggregate at the bleeding site, promoting the formation of a clot and achieving the purpose of hemostasis. In addition, when pH>6, the activity of pepsin is lost, making the fibrin in the clot no longer dissolve, so that the formed clot is no longer digested or destroyed, thus achieving better hemostasis.