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Probability diagnosis

Chronic peptic ulcer (stomach and duodenum) 50%

Acute gastric ulcers/erosions 20%

Oesophagitis (incl. GORD)

Mallory--Weiss (emetogenic) syndrome

Drugs: aspirin, NSAIDs, anticoagulants, clopidogrel, NOACs

Serious disorders not to be missed


  • oesophageal varices

  • blood dyscrasias, e.g. aplastic anaemia

  • vascular malformation/angiodysplasia

  • hereditary coagulopathy


  • gastric or oesophageal


  • chronic liver disease

Pitfalls (often missed)

Stomach ulcer

Swallowed blood (e.g. epistaxis)

Collagen diseases (e.g. scleroderma)


  • ruptured oesophagus

  • hereditary haemorrhagic telangiectasia

  • scurvy

  • ingested poisons (e.g. acid, alkali, arsenic)

  • gastric antral vascular ectasia

Key history

  • Nature of vomitus from fresh blood to ‘coffee grounds’

  • Is bleeding arising from the mouth, nose or pharynx?

  • Indigestion, heartburn or stomach pains

  • Associated symptoms (e.g. weight loss, jaundice)

  • Any bleeding problems

  • Drug history including alcohol, NSAIDs, antiplatelet agents, warfarin, steroids

Key examination

  • Patient’s general state including circulation, vital signs

  • Abdominal examination and rectal examination

  • Evidence of liver disease

Key investigations

  • Upper GIT endoscopy diagnoses bleeding source in 80%

  • FBE

  • LFTs including © GT

  • Helicobacter pylori tests

  • Imaging (e.g. plain erect X-ray, as indicated)

Diagnostic tips

  • Melaena occurs in 50% of cases of haematemesis.

  • Oesophageal bleeding tends to give vomiting fresh blood.

  • ‘Coffee grounds’ vomitus indicates contact with gastric acid.

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