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Clinical Summary

Emesis characteristics that prompt evaluation for life-threatening causes include bilious emesis, hematemesis, projectile vomiting, feculent emesis, prolonged emesis (> 12 hours in a neonate, > 24 hours in children < 2 years old, or > 48 hour in older children), associated mental status change, bradycardia, hypertension, trauma, bulging fontanelle, seizures, abdominal distention, and diminished urine output.

Hematemesis is bloody (see Fig. 24.43) or coffee ground–appearing emesis. Life-threatening causes include esophageal variceal bleeding, swallowed blood from posttonsillectomy bleeding, esophageal rupture, aortoenteric fistulas, epistaxis, arteriovenous malformations, peptic ulcer disease, and upper GI tumors. Volume of blood loss from hematemesis is often overestimated by patients and healthcare workers.

FIGURE 25.43

Hematemesis. Vomiting of clotted blood 4 days after a tonsillectomy and adenoidectomy. (Photo contributor: Lawrence B. Stack, MD.)

Bilious (green) vomiting (see Fig. 25.44) in newborns suggests malrotation with midgut volvulus, a life-threatening surgical emergency. Malrotation occurs because the normal embryological sequence of bowel development, rotation, and fixation within the abdomen is not completed. Malrotation creates an environment where the intestines of the mid-gut can twist on themselves, causing an immediate bowel obstruction and intestinal ischemia.

FIGURE 25.44

Bilious Emesis. Emesis with green color indicating larger amounts of bile in the stomach often associated with intestinal obstruction. (Photo contributor: Jaime Kaye Otillio, MD.)

Feculent vomiting (see Fig. 25.45) is an unusual symptom typically caused by a mechanical intestinal obstruction, but can be due to an adynamic ileus. Other causes include gastrocolic fistula, coprophagy, and violent reverse peristalsis.

FIGURE 25.45

Feculent Emesis. Vomit of fecal origin associated with a gastrocolonic fistula or ileal obstruction. (Photo contributor: Lawrence B. Stack, MD.)

Management and Disposition

Unstable (orthostatic, acute anemia, hypotensive, symptomatic) patients with upper GI bleeding should be admitted to the ICU for continued resuscitation and endoscopy. Stable patients may be admitted to the floor. Consider octreotide, ceftriaxone, pantoprazole, and blood products in unstable patients with variceal bleeds. Linton, Blakemore, and Minnesota tubes are temporary balloon tamponade devices that buy time until patients are stable for endoscopy. Intubation for airway protection is frequently needed in severe variceal bleeds. Patients with Mallory-Weiss tear bleeding may be discharged from the emergency department after a period of observation without continued hematemesis.

Bilious emesis in the infant should prompt immediate pediatric surgery consultation while the evaluation and fluid resuscitation are ongoing. Plain films of the abdomen should be initially obtained, and if there is no free air, an upper GI series should be obtained. Fluid resuscitation should be ongoing.


  1. Emesis of gastric fluid is yellow (see Fig. 25.46) and may be mistaken ...

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