Vomiting blood

Blood in vomit means that somewhere in the upper digestive tract — the oesophagus, the stomach or the start of the duodenum — there is a bleeding source. Until proved otherwise that is how it is treated, and here you cannot wait even an hour. One bleed stops by itself; another takes a dangerous volume of blood in a few minutes, and after a single episode the two are indistinguishable. So the main rule comes first and has no exceptions: vomiting blood means calling an ambulance, not watching and waiting.

This is an ambulance, not watch and wait

Call an ambulance straight away. The single European emergency number 112 works in Spain, Italy, Portugal, Poland and Ukraine; where a different local emergency number applies, use that one.

It is more urgent still if any of the following appears:

• there is a lot of blood — a mouthful, several spoonfuls, a bowlful, or the vomiting of blood keeps happening;
• weakness, dizziness, vision greying out, especially on sitting up or standing;
• pallor, cold clammy skin, sticky sweat;
• a fast pulse, fast or shallow breathing;
• confusion, drowsiness, fainting;
• severe tummy pain or chest pain;
• black tarry stools on their own, even with no vomiting;
• the person takes blood-thinning medicines or has liver disease.

Do not drive yourself. Have someone take you, or wait for the ambulance: with blood loss you can pass out on the way. If the person vomiting blood is a child, a pregnant woman, an older person or someone who has already had an ulcer or cirrhosis, call for help without deliberating.

What the blood looks like and what that tells you

The appearance hints at how recent the bleeding is, but it never removes the need to call for help.

• Fresh bright red blood, sometimes with clots: the bleeding is happening now and is usually heavy. This is how a rupture of widened veins in the oesophagus behaves, and an ulcer that has opened a vessel.
• A brown mass like coffee grounds: the blood has spent time in the stomach and been changed by acid. It points to bleeding that began earlier or is trickling. That does not make it harmless — coffee grounds often come before a heavy episode.
• Streaks of blood after repeated vomiting: the least frightening version, but it still needs looking at, because telling a surface tear from an ulcer is only possible with a doctor's eyes.

Black tarry stools — sticky, shiny, with a strong smell — are the same bleed, only the blood has passed through the bowel. They can be the sole sign even when there has been no vomiting at all, and they deserve the same urgency. Do not confuse them with the plain darkening of stools caused by iron supplements, activated charcoal, blueberries or beetroot: there is none of the stickiness, none of the smell and no feeling unwell.

Try to remember or photograph what came up, and to judge the volume in spoonfuls or glassfuls. That tells a doctor more than a description in words.

What to do and what not to do until help arrives

Lay the person on their side so that blood and vomit cannot go into the airway. If they are conscious and more comfortable half sitting up, let them stay that way.

• Nothing to eat or drink, water included. An urgent look inside the oesophagus and stomach may be needed, and it is done on an empty stomach; water also brings on more vomiting.
• No painkillers. Anti-inflammatory medicines and aspirin damage the lining and increase bleeding — quite often they are the very cause of it.
• Do not stop blood-thinning medicines yourself and do not change the dose. Stopping them is the doctor's decision and is sometimes dangerous in itself. But say straight away that they are being taken, and name them.
• Do not make the person sick and do not wash out the stomach at home.
• No alcohol, and no remedies "for the stomach" given on your own judgement.

Gather the packets of everything the person takes, including anything bought without a prescription, and any hospital letters. That speeds up the doctor's decision.

Where the bleeding comes from

The cause is established in hospital, but knowing the main ones explains why there is such haste.

• A stomach or duodenal ulcer is the commonest cause. It may have been preceded by pain high in the abdomen when hungry or at night, though it is not unusual for bleeding to be the ulcer's first sign.
• Damage to the lining from medicines. Anti-inflammatory painkillers and aspirin taken long term produce erosions and ulcers, often with no pain at all. The risk is higher when these are combined with steroids, with anticoagulants, or with each other.
• Widened veins in the oesophagus in liver disease — the most dangerous of all. In cirrhosis blood passes through the liver poorly and overfills the thin-walled veins of the oesophagus and stomach; when one of them tears the bleeding can be torrential. What points to it: past hepatitis, years of heavy drinking, yellowing of the skin and the whites of the eyes, a swollen abdomen, bruises with no cause.
• A tear in the lining of the oesophagus from violent vomiting. The classic story is several hours of relentless vomiting after which streaks or a little blood appear in it. Such a tear usually heals on its own, but the diagnosis is only made after looking.
• Inflammation of the lining of the stomach and oesophagus from severe reflux or from alcohol.
• Cancer of the stomach or oesophagus. Less common, but it is the first thought if the person is not young and there is weight loss, a lasting loss of appetite, food sticking on the way down, or feeling full very quickly.
• Clotting disorders, either inherited or caused by medicines and by liver disease.

What gets mistaken for vomiting blood

Sometimes the alarm turns out to be false. That is not a reason to work it out at home, but it is worth telling the doctor.

• Swallowed blood from the nose. When a nosebleed starts at the back of the nose, blood runs down the throat, collects in the stomach and later comes up with vomit. Clues: blood came from the nostril as well, there was a recent knock to the nose or very dry air, and there is a trickling sensation at the back of the throat.
• Blood after dental work, or from a gum, a sore in the mouth, a bitten tongue; and in a baby, blood from a cracked nipple while feeding.
• Blood from the throat after tonsil surgery.
• Food and drink that stain: beetroot, red grape juice, wine, pomegranate, tomato purée, jellies and drinks with red colourings; chocolate and coffee resemble coffee grounds.

None of these can be confirmed at home once blood is visible. Until the source is found, act as you would for bleeding from the stomach.

When blood is coughed up rather than vomited

This is the other picture most often confused with vomiting blood: coughing up blood. There the blood comes from the airways, and the diseases, the management and the urgency are different. The difference usually shows in a few features.

• What comes before the blood. With coughing up blood it is a cough, a tickle or a bubbling in the chest. With bleeding from the stomach it is nausea, retching and the effort of vomiting itself.
• The look of the blood. Coughed-up blood is bright red and frothy and is mixed with phlegm. Blood from the stomach is dark and brownish, does not froth, and may contain food.
• What goes with it. Coughing up blood comes with breathlessness, chest pain on breathing in, fever, a cough that has dragged on. Bleeding in the stomach comes with pain high in the abdomen, black tarry stools and signs of liver disease.

Both, when the blood is heavy, need an ambulance, so in the urgent moment there is no need to sort out which is which: call for help and tell the doctor whether the blood was coughed up or vomited. Telling them apart matters afterwards, because it decides whether the lungs or the oesophagus and stomach get examined. We have a separate page on coughing up blood, where the same distinction is drawn from the side of the airways.

How it is investigated and treated

In hospital the first job is to judge how much blood has been lost: blood pressure, pulse, tests for haemoglobin and clotting, blood group. A drip is started and, if the loss is large, blood components are transfused. Medicines that lower stomach acid are given at once, and where widened veins in the oesophagus are suspected, drugs that reduce the pressure in them are added.

The main investigation is gastroscopy: a look at the oesophagus, stomach and duodenum through a thin flexible instrument. It is done urgently, usually within the first hours after the person is stable. It does more than find the source — it allows the bleeding to be stopped on the spot, by closing the vessel with a clip, injecting around it, sealing it with heat, or tying off a widened vein with a rubber band. If that does not work, blocking the vessel through a catheter and surgery remain.

After that the cause is treated: the ulcer is healed and, if the bacterium Helicobacter pylori is found, a course to clear it is given; painkillers are reviewed; in liver disease medicines are prescribed to prevent the veins tearing again, and follow-up appointments are planned. Bleeding recurs above all where the cause was only half treated, so it is worth finishing the course you were given even once you feel entirely well.

Online consultation

If there is blood in the vomit, or there has been, a consultation does not replace calling an ambulance and that is where to start. An online appointment is useful for something else. It helps when it is unclear whether it was blood or a food that stains, and when it is a matter of isolated streaks after repeated vomiting: from your account the doctor can work out where the blood came from, weigh the risk against your medicines and illnesses, and say plainly whether to go in now or book a gastroscopy. After a hospital stay it helps you not to be left alone with the paperwork — explaining the gastroscopy report, checking which painkillers are open to you now, and working out when and how blood-thinning medicines are restarted.

This material is for information only and does not replace medical advice.