51 Regurgitation/Hematemesis Hematemesis is literally translated as bloody vomit and refers to the clinical regurgitation of blood from the upper gastrointestinal/respiratory tract, which includes the nose, mouth, pharynx, esophagus, stomach, and small intestine. Regurgitation is the movement of contents within the upper gastrointestinal tract in a retrograde manner. Because there is limited overlap regarding the causes of hematemesis and regurgitation, they will be considered separately in this chapter. The initial consideration when evaluating a patient with hematemesis is hemo-dynamic stability. In the face of acute large-volume hematemesis immediate airway protection and the initiation of the ABC (airway, breathing, circulation) resuscitation algorithm is required. It should also be noted that without (and occasionally, with) endoscopic evaluation one may be unable to differentiate hematemesis from hemoptysis. Dedicated endoscopic evaluation of the upper aerodigestive tract can separate the sources of hematemesis into those above and those below the esophageal inlet, and therefore into the general purview of the otolaryngologist versus the gastroenterologist, respectively. — Platelet dysfunction — Excessive anticoagulation — Von Willebrand disease — Hemophilia A and B — Idiopathic or thrombotic thrombocytopenic purpura — Medication, such as aspirin — Hereditary hemorrhagic telangiectasia — Collagen-vascular disease — Vascular aneurysm or pseudoaneurysm Hematemesis originating above the esophageal inlet tends to be bright red (unless secondarily regurgitated), and can be caused by the following (from superior to inferior):
Hematemesis
Systemic causes
Any systemic cause of coagulopathy can increase bleeding from various sources.
Acquired or congenital vascular pathology can cause bleeding.
Above the Esophageal Inlet
Nose
Epistaxis: Any cause of epistaxis can potentially result in hematemesis primarily or secondarily through regurgitation. Epistaxis is discussed in detail in Chapter 29. Due to anatomical constraints as well as volume characteristics, posterior epistaxis is more likely to result in clinical hematemesis than anteriorly based bleeds. Maxillofacial trauma can cause anterior or posterior nasal bleeding. A history of recurrent epistaxis in addition to hematemesis is suggestive of a nasal source. A recent history of nasal surgery, endoscopic or open, may also suggest a possible nasal source.
Nasopharynx
Trauma: Recent surgery with nasotracheal intubation could suggest nasopharyngeal laceration.
Surgical bleeding: Recent adenoidectomy should prompt investigation for bleeding in the surgical bed; postadenoidectomy bleeding is usually less profuse than posttonsillectomy bleeding and can be intermittent. Any recent nasal, skull base, or endonasal neurosurgical procedure should raise the question of postsurgical bleeding. Recent ear surgery can result in hemotympanum and passage of blood from the middle ear to the nasopharynx through the eustachian tube.
Neoplasm: The most common lesions include nasopharyngeal carcinoma or juvenile nasopharyngeal angiofibroma. Nasopharyngeal neoplasms may present with a history of unilateral epistaxis, increasing nasal congestion, and/or other nasal complaints.
Internal carotid aneurysm may rarely be responsible for massive nasopharyngeal bleeding.
Oral cavity/oropharynx
Trauma: Recent trauma with mucosal laceration is a common cause of oral bleeding that is usually spotty rather than profuse.
Gingivitis: In adults, severe gingivitis can lead to diffuse bleeding.
Surgical bleeding: History of tonsillectomy, dental work, or other recent oral cavity procedures should prompt investigation. Posttonsillectomy bleeding may be profuse or intermittent; a clot may be visible over the surgical site.
Other
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