Haematemesis
Haematemesis is the vomiting of blood, originating from the upper gastrointestinal tract, indicating conditions such as peptic ulcers, variceal bleeding, or mucosal erosions.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Peptic ulcer disease (most common cause of UGIB) [5][6] | Epigastric pain related to meals; NSAID/aspirin use; H. pylori history | 「個胃有冇痛？食完嘢好啲定差啲？有冇食止痛藥？」 | ~35% |
| Gastritis/duodenitis/erosions | NSAID/aspirin/alcohol-induced; usually self-limiting after drug removal [2] | 「最近有冇飲酒多咗或者食新嘅止痛藥？」 | ~20% | |
| Serious Not To Miss | Oesophageal variceal bleeding [4][5] | Known liver disease/HBV carrier; large-volume haematemesis; stigmata of CLD | 「有冇乙型肝炎？有冇肝硬化？手掌有冇紅？個肚有冇脹？」 | ~10% |
| Gastric cancer | Age > 55, weight loss, dysphagia, early satiety, FHx | 「有冇消瘦？食少少就飽？」 | ~2% | |
| Boerhaave's syndrome (full-thickness rupture) | Mackler's triad: vomiting → excruciating chest pain → surgical emphysema [3] | 「嘔完之後有冇好劇烈嘅胸口痛？」 | < 1% | |
| Aortoduodenal fistula | Hx of aortic graft surgery; herald bleed then massive haemorrhage | 「之前有冇做過大血管手術？」 | < 1% | |
| Pitfalls | Oesophagitis | Heartburn, acid reflux history; usually benign course | 「有冇胃酸倒流？」 | ~10% |
| Mallory-Weiss tear [3][5] | Forceful vomiting/retching preceding haematemesis; usually small volume; 90% stops spontaneously | 「嘔血之前有冇嘔得好犀利？」 | ~7% | |
| Swallowed blood (epistaxis/dental) | History of nosebleed or dental procedure | 「最近有冇流鼻血或者牙齒出血？」 | ~3% | |
| Haemoptysis misidentified | A/w cough, frothy, bright red, no melaena [8] | 「嗰啲血係嘔出嚟定係咳出嚟？」 | ~2% | |
| Masquerades | Drugs (NSAIDs, aspirin, anticoagulants) | Temporal relationship to drug initiation/dose change | 「最近有冇轉藥或者加藥？」 | ~20% |
| Coagulopathy/thrombocytopenia | Easy bruising, petechiae; on warfarin/DOACs | 「有冇容易瘀？有冇食薄血丸？」 | ~3% | |
| Trying to Tell Me Something? | NSAID self-medication for chronic pain | Buying OTC painkillers; not telling doctor | 「有冇自己買止痛藥食？」 | ~15% |
| Alcohol dependence (not disclosing) | Hiding alcohol intake; depression | 「你最近壓力大唔大？心情點？」 | ~10% | |
| Cancer anxiety | Family member with GI cancer; health anxiety | 「你係咪擔心自己生cancer？」 | ~5% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, intro, rapport | 「你好，我係X醫生，今日由我幫你睇症。你可以叫我X醫生。請問點稱呼你？」 | Friendly opening, establishes rapport, uses patient's name |
| 0:30–1:30 | Chief complaint + HPI – nature of vomiting, amount, colour, duration, frequency, associated melaena/PR bleed | 「你今日嚟睇咩事呢？」→「你嘔嗰啲血係咩色？鮮紅色定係啡色好似咖啡渣咁？」→「嘔咗幾多？幾多次？幾時開始？」→「有冇屙黑色大便？」 | Establishes CC; characterises bleeding — haematemesis vs coffee ground vomiting [1] |
| 1:30–3:00 | Red flags + associated Sx – syncope/dizziness, epigastric pain, weight loss, dysphagia, preceding forceful vomiting, liver disease symptoms, drug history (NSAIDs/aspirin/anticoagulants) | 「有冇頭暈或者暈低過？」→「個肚有冇痛？食嘢前定後痛？」→「有冇食止痛藥、薄血藥、阿士匹靈？」→「有冇消瘦、吞嘢困難？」→「之前有冇嘔好勁之後先出血？」 | Identifies severity & aetiology; captures drug history which is crucial for PUD/gastritis [2][3] |
| 3:00–4:00 | PMHx, FHx, social Hx – liver disease/Hep B carrier, alcohol, smoking, H. pylori Hx, occupation, stress | 「以前有冇乙型肝炎？有冇肝硬化？」→「平時飲唔飲酒？飲幾多？」→「有冇食煙？」→「之前有冇照過胃鏡？」 | Variceal bleed vs PUD distinction; alcohol/HBV key in HK [4] |
| 4:00–5:00 | ICE – Ideas, Concerns, Expectations | 「你自己覺得嘔血係咩原因？」(Idea)→「你最擔心啲咩？」(Concern)→「你今日嚟最希望醫生可以幫到你啲咩？」(Expectation) | Direct marks for ICE; uncovers hidden agenda |
| 5:00–5:30 | Summarise back | 「等我總結返，你喺X日開始嘔血…我有冇漏咗咩？」 | Shows active listening; checks accuracy |
| 5:30–6:00 | Safety net + close | 「依家最重要係幫你安排抽血同照胃鏡。如果你再嘔好多血、頭暈、甚至暈低，一定要即刻去急症室。」→「你有冇嘢想問我？」 | Safe closure; urgent referral plan scores marks |
Uncovering the Hidden Agenda
The patient may present with haematemesis but the real worry could be cancer fear (especially if family member died of gastric/liver cancer), anxiety about stopping aspirin (cardiovascular risk), or alcohol dependence they haven't disclosed. Always ask: 「你最擔心啲咩？有冇其他嘢想同我傾？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Nature | What colour was the vomit – bright red or coffee-ground? | 「嘔出嚟嗰啲血係鮮紅色定啡色好似咖啡渣？」 | Haematemesis = moderate-severe bleed or proximal source; coffee ground = slower bleed with oxidation [1][5] | Fresh red → variceal/arterial PUD; Coffee ground → gastritis/slow PUD |
| Volume/Freq | How much and how many times? | 「大約嘔咗幾多？幾多次？」 | Gauges severity & need for emergency OGD | Large volume → variceal, Forrest Ia/Ib |
| Onset | When did it start? Sudden or gradual? | 「幾時開始？突然定慢慢嚟？」 | Acute onset → PUD perforation/variceal | Sudden massive → variceal |
| Melaena | Any black tarry stool? | 「有冇屙過黑色大便，好似芝麻糊咁，好臭？」 | Confirms UGIB; fresh melaena = ongoing bleed [1] | UGIB confirmed |
| Haematochezia | Any fresh blood in stool? | 「有冇屙鮮血？」 | Fresh PR bleed in UGIB = profuse/fast bleeding [1][3] | Massive UGIB |
| Syncope/dizziness | Any fainting or dizziness? | 「有冇頭暈或者暈低過？」 | Haemodynamic compromise | Significant blood loss; urgent referral |
| Epigastric pain | Any tummy pain? Related to meals? | 「個胃有冇痛？食嘢之前定之後痛啲？」 | PUD = most common cause [5][6] | GU: pain worse with food; DU: pain relieved by food |
| Preceding vomiting | Did you vomit forcefully before the blood came? | 「嘔血之前有冇嘔得好勁？」 | Mallory-Weiss tear = longitudinal mucosal tear after violent retching [3][5] | Mallory-Weiss syndrome |
| Dysphagia/weight loss | Any trouble swallowing? Unintentional weight loss? | 「吞嘢有冇困難？有冇消瘦？」 | Red flags for oesophageal/gastric malignancy [7] | Oesophageal/gastric cancer |
| Drug Hx | Taking aspirin, NSAIDs, blood thinners, steroids? | 「有冇食阿士匹靈、止痛藥、薄血藥、類固醇？」 | NSAIDs/aspirin → gastritis/PUD; almost all patients on aspirin develop mild hemorrhagic gastritis [2] | Drug-induced gastritis/PUD |
| PMHx – Liver | Any hepatitis B carrier? Liver cirrhosis? | 「有冇乙型肝炎帶菌？有冇肝硬化？」 | Variceal haemorrhage accounts for 5% of UGIB but 80% of mortality [5] | Oesophageal/gastric varices |
| PMHx – H. pylori | Ever tested/treated for H. pylori? | 「有冇驗過或者醫過幽門螺旋桿菌？」 | H. pylori = major PUD risk | Recurrent PUD |
| Alcohol | How much alcohol do you drink? | 「平時飲唔飲酒？一日飲幾多？飲咗幾耐？」 | Alcohol → gastritis, cirrhosis/varices, MWS [4] | Alcoholic liver disease, Mallory-Weiss |
| Smoking | Do you smoke? | 「有冇食煙？食幾多？」 | Smoking = PUD risk factor | PUD |
| Previous OGD/surgery | Ever had an endoscopy or stomach surgery? | 「之前有冇照過胃鏡？做過胃部手術？」 | Prior PUD, known varices | Recurrent disease |
| Heartburn/reflux | Any heartburn or acid reflux? | 「有冇胃酸倒流、心口灼熱？」 | Oesophagitis = 13% of UGIB [5] | Erosive oesophagitis |
| FHx | Family history of stomach/liver cancer? | 「屋企人有冇胃癌或者肝癌？」 | Cancer risk | Gastric cancer |
| Functional impact | How has this affected your daily life? | 「呢件事對你日常生活有冇影響？」 | Biopsychosocial assessment | Psychosocial problem |
| ICE | What do you think is the cause? What worries you most? What do you hope I can do? | 「你覺得係咩原因？你最擔心啲咩？你最希望我幫到你咩？」 | Direct exam marks | Hidden agenda – cancer fear, med non-compliance |
Case Report Form Answer Builder
Write: "Haematemesis × [duration], [volume/frequency], [colour: fresh red / coffee ground], associated with [melaena / epigastric pain / dizziness]. Background of [NSAID use / H. pylori / liver disease / alcohol]."
Key HPI elements to capture:
- Onset, duration, number of episodes, volume estimation
- Colour: fresh red vs coffee ground → fresh red = moderate-severe bleed; coffee ground = small/slow bleed oxidised in stomach [1][5]
- Associated: melaena (confirms UGIB), syncope/postural symptoms (severity), epigastric pain (PUD), forceful vomiting (MWS)
- Drug history: NSAIDs/aspirin/anticoagulants [2][3]
- Risk factors: alcohol, smoking, H. pylori, known liver disease
| Likely RFC Examples | Best Phrasing |
|---|---|
| Acute vomiting of blood causing alarm | "Haematemesis" or "Vomiting blood" |
| Worried about cause of bleeding | "To find out the cause of vomiting blood" |
| Referred by A&E / self-presenting with acute bleed | "Acute upper GI bleeding requiring urgent assessment" |
Tip: The ONE main RFC should be the reason not the diagnosis. e.g., "Vomiting blood" or "Haematemesis — concerned about the cause."
| Component | Likely Content | Exact Wording to Write |
|---|---|---|
| Ideas | "I think it's from my stomach ulcer" / "Maybe something I ate" / "Worried it's cancer" | "Patient thinks the bleeding may be from a stomach ulcer / worried it could be stomach cancer" |
| Concerns | Cancer fear; fear of endoscopy; worry about stopping aspirin (cardiac risk) | "Patient is worried this could be cancer" / "Concerned about having to stop aspirin" |
| Expectations | Wants endoscopy; wants reassurance; wants medication | "Patient hopes to have an endoscopy to find the cause and receive treatment to stop the bleeding" |
| DDx | Key Discriminator |
|---|---|
| 1. Oesophageal variceal bleeding | Known CLD/HBV carrier; large-volume haematemesis; stigmata of chronic liver disease [4][5] |
| 2. Mallory-Weiss tear | Forceful vomiting/retching preceding haematemesis; usually small volume [3] |
| 3. Gastric cancer | Age > 55; unintentional weight loss; dysphagia; early satiety; persistent epigastric pain [7] |
| Domain | Problem |
|---|---|
| Biological | Acute blood loss with risk of haemodynamic instability; anaemia |
| Psychological | Anxiety/fear of cancer or serious disease; fear of endoscopy |
| Social | Functional impairment (unable to work/eat normally); if alcohol-related — impact on family/occupation; if on aspirin — dilemma of stopping antiplatelet vs cardiac risk |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| PUD (most likely) | Epigastric tenderness | Palpate epigastrium with flat hand; note tenderness without guarding (unless perforated) | Localised tenderness at ulcer site; most consistent exam finding in uncomplicated PUD [6][9] |
| Oesophageal varices | Stigmata of chronic liver disease — spider naevi, palmar erythema, jaundice, caput medusae, splenomegaly, ascites | Inspect hands, face, chest, abdomen; palpate for splenomegaly; percuss for shifting dullness | Indicates portal hypertension → variceal source [4][5][9] |
| Mallory-Weiss tear | No reliable physical sign in brief FM station | Best clue is history of forceful vomiting preceding haematemesis; examination may be unremarkable | Diagnosis is clinical + endoscopic [3] |
| Gastric cancer | Palpable epigastric mass (late finding); supraclavicular lymph node (Virchow's node) | Deep palpation of epigastrium; palpate left supraclavicular fossa | Suggests advanced gastric malignancy [7] |
High-Yield GC Lecture Point
Features suggestive of ongoing bleeding: haematemesis, fresh melaena, tachycardia, fresh PR bleeding, fresh blood aspirated from NG tube [1]. This was directly listed on GC 198 slides — very likely to appear on in-house exams. If asked "List clinical features of recurrent/ongoing bleeding," reproduce this list.
Top traps that lose marks:
- Confusing haematemesis with haemoptysis — always ask: 「係嘔出嚟定咳出嚟？」 Haemoptysis is a/w cough, frothy, bright red, no melaena [8]
- Forgetting drug history — NSAIDs/aspirin are the #1 modifiable cause; almost all patients on aspirin develop hemorrhagic gastritis [2]. Missing this loses both history AND management marks.
- Not asking about liver disease / HBV — In Hong Kong, HBV is endemic. Variceal bleeding = 5% of UGIB but 80% of mortality [5]. Missing this is a critical safety lapse.
- Not assessing severity — Must ask about syncope, postural symptoms, volume, frequency. Postural hypotension indicates ≥ 20% blood volume loss [5].
- Writing "upper GI bleeding" as the diagnosis instead of the specific cause — the examiner wants "peptic ulcer disease" or "oesophageal variceal bleeding," not just "UGIB."
- Forgetting ICE — Direct marks. Cancer fear is the most common hidden concern.
- Mixing up Mallory-Weiss (mucosal tear, self-limiting) with Boerhaave's (full-thickness rupture, life-threatening) — MWS: 90% stops spontaneously. Boerhaave's: Mackler's triad with surgical emphysema [3].
Must-not-miss red flags → urgent referral:
- Haemodynamic instability (tachycardia, hypotension, syncope)
- Large-volume fresh haematemesis
- Suspected variceal bleeding (known CLD)
- Signs of perforation (peritonism, surgical emphysema)
- Constitutional symptoms suggesting malignancy
Shortest safe management/safety-net line:
「依家最重要安排你入院抽血同照胃鏡。如果你再嘔大量血、頭暈、暈低、或者心跳好快，一定即刻叫白車去急症室。」
High Yield Summary
What to ASK: Colour/volume of vomit, melaena, syncope/dizziness, epigastric pain, drug history (NSAIDs/aspirin/anticoagulants), alcohol, HBV/liver disease, H. pylori history, preceding forceful vomiting, weight loss/dysphagia, ICE.
What to WRITE: CC = "Haematemesis"; Most likely Dx = Peptic ulcer disease; DDx = variceal bleeding, Mallory-Weiss tear, gastric cancer; Physical sign = epigastric tenderness (PUD) or stigmata of CLD (varices); Biopsychosocial = acute blood loss + cancer anxiety + functional/occupational impact.
What NOT to MISS: Drug history (NSAIDs/aspirin), liver disease/HBV status, haemodynamic assessment, and differentiating haematemesis from haemoptysis. Features of ongoing bleeding: haematemesis, fresh melaena, tachycardia, fresh PR bleed [1].
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 198. Profuse vomiting of fresh blood and in shock severe upper GI bleeding.pdf (p2, p20) [2] Senior notes: Block A - Coffee ground vomitus tarry stool upper GI bleeding.pdf (p22 — gastritis/NSAIDs section) [3] Senior notes: Maksim Surgery Notes.pdf (p52–53, p59 — UGIB, Mallory-Weiss, Boerhaave's) [4] Senior notes: Maksim Medicine Notes.pdf (p124 — oesophageal varices) [5] Senior notes: Ryan Ho GI.pdf (p38–41 — causes and clinical approach to UGIB) [6] Senior notes: Block A - Introduction to GI_Hepatology investigations (LFT, Endoscopy).pdf (p21 — causes of acute UGIB, peptic ulcer most common) [7] Lecture slides: GC 212. Weight loss and vomiting gastric cancer; abdominal imaging.pdf (p24) [8] Lecture slides: Respiratory Four cases of Haemoptysis.pdf (p39 — differentiation from haematemesis) [9] Past papers: 2022 Fourth Summative Minicase.pdf (Case One — haematemesis with CLD stigmata)
Fits, Faints And Funny Turns
Fits, faints, and funny turns is a clinical umbrella term for transient episodes of altered consciousness or awareness, encompassing seizures, syncope, and other paroxysmal events that require systematic differentiation to identify their underlying neurological, cardiac, or metabolic cause.
Haematuria
Haematuria is the presence of red blood cells in the urine, which may be visible (gross) or detectable only on microscopy (microscopic), indicating potential urological, nephrological, or systemic disease.