Hematemesis or blood in emesis can occur as recent or ongoing hemorrhage proximal to the ligament of Treitz. Hematemesis is relatively uncommon in the pediatric population, and its overall occurrence in an ambulatory setting has not been reported. The most common diagnoses vary based on the age of presentation of the patient.

Differential Diagnosis :-

• Gastritis

• Esophagitis

• Peptic ulcer disease

• Zollinger-Ellison syndrome

• Milk protein allergy

• Eosinophilic enteropathy

• Portal hypertension

• Traumatic

• Vascular malformations

• Tumors

• Miscellaneous 

Workup and Diagnosis :-

History :-
–Quantity, frequency, type of blood (bright red vs “coffee grounds”); abdominal pain
–Dysphagia/odynophagia, chest pain/burning, hematochezia, melena, bruising, bleeding
–Birth history: Stressors, medications before delivery, medications in delivery room
  (vitamin K), lines placed (umbilical lines can result in clotting of portal vein)
–Past history: History of liver disease, ingestions, history of pancreatitis, GI surgeries
–Medications: NSAID use, aspirin use, recent meds
–Diet history: Formula intolerance, food allergies

Physical exam :-
–Vital signs (tachycardia, tachypnea, hypotension), blood in nares, conjunctival/palatal
  pallor, flow murmur, hepatosplenomegaly, abdominal tenderness, abdominal bruising,
  petechiae

Diagnostics :-
–Limited labs: CBC, liver function tests, coagulation studies, type and screen/cross
–Upper endoscopy most sensitive and specific for diagnosis and provides therapeutic 
  options
–Ultrasound with Doppler to assess liver disease and portal hypertension
–Reserve nuclear medicine studies (e.g., tagged red cell study, angiography) as second
  line and for brisk bleeding


Treatment :-

• Large bleeds require two large-bore IVs and volume support with normal saline or packed red blood cells

• Closely monitor vital signs

• Acid blockade with histamine receptor antagonist or proton pump inhibitor

• Endoscopic therapy including
  – Heater probe and bipolar coagulation for ulcers
  – Band ligation or sclerotherapy for varices

• Octreotide or vasopressin to reduce splanchnic blood flow for variceal bleeding

• Selective embolization

• Surgical repair rarely indicated

• Treat infections including triple therapy (antibiotics and proton pump inhibitor) for H. pylori

• Remove allergen in case of allergy