Стомашно-чревно кървене: повръщане на кръв и черни изпражнения¶

Острото стомашно-чревно (GI) кървене е спешно медицинско състояние, при което кръвта изтича от спукан кръвоносен съд, язва или разкъсване навсякъде по протежение на храносмилателния тракт, от хранопровода и стомаха (горен GI кървене) надолу към тънките черва, дебелото черво и ректума (долен GI кървене). За разлика от външната рана на ръката или крака, не можете да притискате ръцете си директно върху кървяща стомашна язва или разкъсан варикс на хранопровода, а стомахът и червата могат безшумно да скрият 1000 до 2000 милилитра (2 до 4 пинти) кръв преди една капка да бъде повърната или изпусната в тоалетната. Независимо дали някой повръща яркочервена кръв или тъмен "кафен" материал (хематемеза), отделя лепкави черни като катран изпражнения (мелена) или отделя големи количества кестенява или яркочервена кръв от ректума (хематохезия), вашите непосредствени приоритети са да се обадите на спешна медицинска помощ, да преобърнете повръщащ човек настрани, за да не се удави в аспирирана кръв, като ги пазите стриктно нищо през устата (NPO) и ги поставяте легнали, за да предотвратите фатален хиповолемичен шок.

Направете това сега¶

1. Незабавно се обадете на вашия местен номер за спешни повиквания, ако лицето повръща кръв, отделя черни катранени изпражнения със замаяност или има силно кървене от ректума. Наберете 911 в Съединените щати и Канада, 112 в Европейския съюз, 999 в Обединеното кралство или вижте всички номера за спешни случаи. Кажете на диспечера дали пациентът повръща яркочервена кръв, има чернодробна цироза или приема разредители на кръвта (антикоагуланти), тъй като това задейства усъвършенствани парамедицински дихателни пътища и протоколи за кръвопреливане.
2. Защитете дихателните пътища, като поставите всеки повръщащ или сънлив човек на една страна (позиция за възстановяване). Ако човекът активно повръща кръв (хематемеза), повръща или става сънлив, объркан или в безсъзнание, незабавно го превъртете на лявата страна в страничната позиция за възстановяване и наклонете брадичката му леко надолу, така че кръвта и съсиреците да изтичат свободно от ъгъла на устата си в леген или кърпа. Използвайте пръст, увит в кърпа, за да почистите всички големи гумени кръвни съсиреци от предната част на устата им, ако се запушват.
3. Положете неповръщащ и замаян човек по гръб, за да предотвратите припадък и шок. Не не позволявайте на човек със съмнение за стомашно-чревно кървене да слиза по стълбите, да стои до мивката в банята или да седи изправен на тоалетната, ако се чувства замаян. Стоенето изправено, когато обемът на кръвта е изчерпан, причинява рязко спадане на кръвното налягане (ортостатичен синкоп), което води до внезапен колапс, тежки наранявания на главата върху плочките в банята и сърдечен арест. Ако са напълно будни и не им се гади или повръщат, поставете ги легнали на пода или леглото.
4. Давайте строго НИЩО през устата (без вода, без мляко, без антиациди и никога аспирин или НСПВС). Не позволявайте на лицето да пие вода, мляко или билкови чайове и не давайте перорални антиациди или бисмут. Най-важното е, че никога не давайте аспирин, ибупрофен (Advil, Motrin), напроксен (Aleve), диклофенак или кеторолак за болки в стомаха: тези нестероидни противовъзпалителни лекарства (НСПВС) премахват защитната слузна бариера на стомаха и парализират тромбоцитите, превръщайки бавното кървене от язва в проливен артериален кръвоизлив.
5. Затоплете човека с одеяла, за да предпазите съсирването на кръвта. Покрийте пациента с топло одеяло или палто и поставете одеяло под него, ако лежи на студен под в банята. Когато на кървящ пациент стане студено (хипотермия под \(35^\circ\text{C}\) или \(95^\circ\text{F}\)), ензимната каскада на съсирването и кръвните плочици спират да работят правилно (част от „смъртоносната триада на травма и кръвоизлив“), причинявайки неконтролируемо кървене.
6. Запазете проба или направете снимка на смартфон на повръщаното или изпражненията и съберете всички бутилки с лекарства. Преди да пуснете водата в тоалетната или да изхвърлите леген с повърнато, направете ясна снимка с телефона си или запазете контейнера, за да го покажете на парамедиците (лекарите трябва да видят точния цвят, съсиреци и приблизителен обем). Съберете всяка бутилка с рецепта и без рецепта в къщата, като специално проверявате за разредители на кръвта (варфарин, апиксабан, ривароксабан, дабигатран, клопидогрел), аспирин/НСПВС, стероиди и добавки на желязо или бисмут.

Схема за сортиране на стомашно-чревно кървене и решение за първа помощ¶

Използвайте това дърво за клинични решения, за да идентифицирате източника и тежестта на кървенето от храносмилателния тракт и да предприемете незабавни животоспасяващи стъпки.

flowchart TD
    Start["Suspected Gastrointestinal (GI) Bleeding:<br/>Blood in Vomit, Black Tarry Stool, or Red Rectal Bleeding"] --> AirwayShock{"Check Airway & Shock Signs Immediately:<br/>- Vomiting bright red blood or coffee-grounds?<br/>- Dizzy, fainting, pale, cold clammy sweat?<br/>- Fast heart rate (>100 bpm), confusion, or liver disease?"}

    AirwayShock -->|"YES: Active Hematemesis or Shock"| Emergency911["1. Call 911 / 112 / 999 Immediately<br/>2. If vomiting or drowsy: Roll into Left Lateral Recovery Position<br/>3. If alert & NOT vomiting: Lay flat on back<br/>4. Keep Strictly Nothing by Mouth (NPO)<br/>5. Cover with warm blanket & monitor breathing"]

    AirwayShock -->|"NO: Awake, stable, not vomiting"| StoolColor{"What does the stool or toilet bowl look like?"}

    StoolColor -->|"Jet-Black, Sticky, Tarry Stool<br/>with Foul Odor (Melena)"| MelenaCheck{"Did patient take Iron pills, Pepto-Bismol,<br/>activated charcoal, or black licorice?"}
    MelenaCheck -->|"No (or unsure)"| MelenaER["TRUE MELENA = Upper GI Bleed (>50 to 100 mL blood in stomach):<br/>Go to Hospital Emergency Department Immediately<br/>(Call 911 / 112 / 999 if elderly, on blood thinners, or weak)<br/>Do NOT drive yourself; stay Nothing by Mouth"]
    MelenaCheck -->|"Yes, and ZERO stomach pain,<br/>dizziness, or weakness"| Pseudomelena["Likely Pseudomelena (harmless dark green/black staining):<br/>Contact physician same day to confirm with fecal occult blood test"]

    StoolColor -->|"Large volume Maroon Clots or<br/>Bowl Full of Bright Red Blood (Hematochezia)"| BriskLower["Brisk Lower GI Bleed (or Massive Rapid Upper GI Bleed):<br/>Call 911 / 112 / 999 or Emergency Hospital Transport Immediately<br/>Lay flat, keep warm, bring all blood thinner bottles"]

    StoolColor -->|"Small streaks of bright red blood ONLY<br/>on toilet paper after hard stool"| MinorAnorectal["Likely Hemorrhoids or Anal Fissure:<br/>Schedule prompt doctor evaluation to rule out colorectal polyps/cancer<br/>Go to ER immediately if bleeding does not stop or dizziness develops"]

Decoding the 4 visual patterns of GI bleeding: What color tells you¶

As blood travels through the human digestive tract, stomach hydrochloric acid, digestive enzymes (pepsin), and intestinal bacteria chemically alter the red hemoglobin molecule inside red blood cells, changing its color from bright crimson to dark brown-black. By looking closely at what was vomited or passed into the toilet, you can pinpoint where the bleeding is coming from and how fast it is happening.

False alarms: Distinguishing real blood from harmless food and pill staining ("Pseudomelena")¶

Before panicking over a dark or reddish stool in someone who feels completely healthy, has a normal pulse, and has zero dizziness or stomach pain, check whether they consumed one of these common mimics in the past 24 to 48 hours:

• Harmless mimics of Black Melena ("Pseudomelena"):
• Oral Iron Supplements (ferrous sulfate, ferrous gluconate, prenatal vitamins): Turns stool a dark greenish-black color, but the stool has a normal firm shape (not sticky tar) and lacks the putrid odor of digested blood.
• Bismuth Subsalicylate (Pepto-Bismol, Kaopectate): Bismuth reacts with trace sulfur in saliva and the gut to form black bismuth sulfide, often turning both the tongue and the stool jet-black.
• Activated Charcoal, black licorice, dark chocolate/Oreo cookies, or large bowls of dark blueberries/grape juice.
• Harmless mimics of Red Hematochezia / Red Vomit:
• Red beets (beetroot / betanin pigment), red gelatin (Jell-O), Kool-Aid / red sports drinks, red food coloring, dragon fruit, or large amounts of tomato sauce.
• Safety Rule: If there is any doubt whatsoever, or if the person has stomach pain, weakness, sweating, or takes aspirin/blood thinners, always treat it as real blood and go to the emergency room (a 30-second hospital fecal occult blood test or hemoglobin fingerstick settles the question immediately).

Major causes of upper and lower gastrointestinal bleeding¶

Understanding what causes GI bleeding helps you give critical medical history to the paramedics and emergency physicians.

1. Upper GI bleeding causes (75% to 80% of all hospital GI bleed admissions)¶

• Peptic Ulcer Disease (Gastric and Duodenal Ulcers: 40% to 50% of upper bleeds): Deep sores eroded into the lining of the stomach or the first part of the small intestine (duodenum), almost always caused by either Helicobacter pylori (H. pylori) bacterial infection or regular use of NSAID painkillers (ibuprofen, naproxen, aspirin, meloxicam, diclofenac). When an ulcer eats down into the submucosa and erodes the wall of a major artery (such as the gastroduodenal artery behind the duodenum or the left gastric artery), blood spurts under high arterial pressure into the gut.
• Esophageal and Gastric Varices (10% to 20% of upper bleeds, highest mortality): In patients with liver cirrhosis (from alcohol use, hepatitis B or C, or fatty liver disease) or portal vein thrombosis, scar tissue in the liver blocks normal blood flow from the intestines. Pressure backs up in the portal vein (portal hypertension), forcing blood to detour through fragile, thin-walled veins lining the lower esophagus and upper stomach (varices), which swell like varicose veins. When a varix ruptures, it causes painless, explosive projectile vomiting of hundreds of milliliters of bright red blood and carries a 15 to 20 percent mortality rate per bleeding episode.
• Mallory-Weiss Tear (5% to 15% of upper bleeds): A longitudinal laceration (tear) in the mucous membrane at the junction where the esophagus meets the stomach, triggered by violent retching, dry heaving, or forceful vomiting (after heavy alcohol binge drinking, food poisoning, hyperemesis gravidarum in pregnancy, or severe coughing fits). Typically starts with several episodes of normal vomit followed suddenly by bright red blood.
• Erosive Gastritis, Esophagitis, and Dieulafoy Lesion: Diffuse pinpoint bleeding from severe acid reflux, alcohol, critical illness stress, or a Dieulafoy lesion (an abnormally large, tortuous submucosal artery in the upper stomach that erodes through a tiny mucosal defect and causes massive sudden bleeding without an ulcer).

2. Lower GI bleeding causes (Colon, Rectum, and Small Bowel)¶

• Diverticular Bleeding (Diverticulosis: 30% to 50% of brisk lower bleeds): Small pouch-like herniations (diverticula) in the muscular wall of the colon, common in adults over age 50, form right where penetrating nutrient arteries (vasa recta) pierce the colon wall. If a vasa recta artery inside a diverticulum ruptures, it causes sudden, completely painless passing of large amounts of maroon or bright red blood and clots into the toilet.
• Angiodysplasia (Vascular Ectasias): Fragile, twisted tangles of dilated capillaries and veins in the wall of the right colon or small intestine, common in older adults, patients with chronic kidney disease, or patients with aortic stenosis (Heyde's syndrome).
• Ischemic Colitis, Inflammatory Bowel Disease (Ulcerative Colitis / Crohn's Disease), and Infectious Colitis: Unlike diverticular bleeding (which is usually painless), these conditions cause crampy lower abdominal pain paired with bloody diarrhea or mucus.
• Colorectal Polyps and Colorectal Cancer: Often cause slow, chronic oozing leading to iron-deficiency anemia, or intermittent dark red streaks mixed into the stool fabric.
• Hemorrhoids and Anal Fissures: Swollen veins in the anal canal (hemorrhoids) or a sharp tear in the anal lining (fissure, which feels like "passing broken glass" during a bowel movement) typically coat the outside of the stool or drip bright red blood onto the toilet paper after wiping.

Recognizing hypovolemic shock: Why normal blood pressure can be a lie¶

An average adult body holds roughly 5,000 milliliters (5 liters / 10.5 pints) of blood. When a person bleeds into their stomach or colon, the body immediately unleashes a rush of adrenaline to constrict blood vessels and speed up the heart, which keeps systolic blood pressure looking deceptively normal until the patient has already lost 30 percent (1.5 liters) of their blood.

Use the American College of Surgeons Advanced Trauma Life Support (ATLS) hemorrhage classification to recognize early shock before blood pressure crashes:

Critical warnings: Liver cirrhosis, blood thinners, and aortoenteric fistula¶

If the bleeding person belongs to any of these three high-risk groups, inform the 911 / 112 / 999 dispatcher and paramedics in your very first sentence:

1. Known or Suspected Liver Disease / Cirrhosis (Variceal Bleed): Look for yellow eyes/skin (jaundice), a swollen fluid-filled belly (ascites), spider-like red blood vessels on the chest (spider angiomata), or red palms (palmar erythema). Variceal hemorrhage requires immediate hospital intravenous terlipressin or octreotide (to lower portal vein pressure), prophylactic IV antibiotics (ceftriaxone), and emergency endoscopic variceal band ligation within 12 hours.
2. Patients Taking Anticoagulants ("Blood Thinners") or Dual Antiplatelet Therapy: Check if the patient takes warfarin (Coumadin), Direct Oral Anticoagulants (apixaban [Eliquis], rivaroxaban [Xarelto], edoxaban [Savaysa], dabigatran [Pradaxa]), or antiplatelets (clopidogrel [Plavix], prasugrel, ticagrelor, aspirin). Hospital emergency departments carry specific intravenous reversal antidotes (4-factor Prothrombin Complex Concentrate [Kcentra/Beriplex] + IV Vitamin K for warfarin; andexanet alfa for apixaban/rivaroxaban; idarucizumab [Praxbind] for dabigatran) that can stop fatal bleeding if the medical team knows which pill the patient takes and when the last dose was swallowed.
3. Prior Abdominal Aortic Aneurysm (AAA) Graft Surgery ("Herald Bleed" of an Aortoenteric Fistula): If a person who has ever had an open or endovascular surgical graft placed on their abdominal aorta develops any gastrointestinal bleed (even a small, self-stopping episode of hematemesis or melena), it is a surgical emergency until proven otherwise. A synthetic aortic graft can slowly erode into the wall of the adjacent third part of the duodenum, creating an aortoenteric fistula; a small "herald bleed" is often followed hours or days later by catastrophic, fatal exsanguination directly from the aorta into the gut unless repaired in the operating room.

Специални съображения: Стомашно-чревно кървене при деца и поглъщане на батерия¶

When an infant, toddler, or older child vomits blood or passes dark or bloody stools, both the causes and the critical blood volume thresholds differ dramatically from adults. Because a child's circulating blood volume is only 70 to 80 milliliters per kilogram of body weight (meaning a 10 kilogram [22 pound] 1-year-old has only 750 milliliters of total blood in their entire body), losing just 150 to 200 milliliters (less than one cup) of blood places a toddler in immediate hypovolemic shock.

• Swallowed Button Battery (Aortoesophageal Fistula Emergency): If a young child vomits even a tiny drop or streak of bright red blood or coffee-ground material, ask immediately if they could have swallowed a lithium coin-cell button battery (even up to 2 to 4 weeks ago, as liquefaction necrosis can erode from the esophagus into the aorta days after battery removal). Call 911 / 112 / 999 immediately and do not give anything by mouth once hematemesis has occurred.
• Intussusception ("Currant Jelly" Stools in Infants 3 Months to 3 Years): If a baby or toddler suddenly draws their knees up to their chest with screaming bouts of colicky abdominal pain every 15 to 20 minutes, followed by lethargy, vomiting, and passing dark red, mucus-filled stools that look like red currant jelly, one segment of their intestine has telescoped inside another (intussusception). This requires immediate emergency hospital ultrasound and air-enema reduction to prevent bowel necrosis and perforation.
• Swallowed Maternal Blood or Epistaxis (Nosebleed) Blood: Sometimes a breastfeeding newborn vomits blood or passes dark stools simply from swallowing maternal blood from a cracked nipple, or an older child vomits coffee-ground blood after swallowing blood from a posterior nosebleed overnight. Even so, a doctor must evaluate the child to rule out true mucosal bleeding, Meckel's diverticulum (painless brick-red rectal bleeding in toddlers), or juvenile polyps.

What to expect in the hospital emergency department: Risk scores and endoscopic hemostasis¶

Knowing what happens once the ambulance arrives at the emergency room helps family members provide clear consent and medication histories:

1. Two Large-Bore Intravenous Lines and Restrictive Blood Transfusion: Emergency nurses immediately place two large-bore intravenous cannulas (16-gauge or 18-gauge) into the forearm or antecubital veins, draw blood for a complete blood count, coagulation panel (INR), lactate, and blood type/crossmatch, and infuse warm balanced crystalloid fluids (Ringer's lactate or \(0.9\%\) normal saline). Modern randomized clinical trials (validated by the ACG, ESGE, and UK NICE) show that a restrictive packed red blood cell transfusion threshold (transfusing when hemoglobin drops to \(7\text{ g/dL}\) [\(70\text{ g/L}\)] in most patients, or \(8\text{ g/dL}\) [\(80\text{ g/L}\)] in patients with active coronary heart disease) saves more lives than over-transfusing, because over-transfusing raises portal and arterial blood pressure and blows off newly formed clots.
2. Glasgow-Blatchford Score (GBS) and Intravenous Medication: Doctors calculate the Glasgow-Blatchford Score (using blood urea nitrogen, hemoglobin, systolic blood pressure, pulse rate, melena, syncope, liver disease, and heart failure) to determine severity. Patients receive high-dose intravenous proton pump inhibitors (such as pantoprazole or esomeprazole) to neutralize stomach acid so platelets can clot, prokinetic erythromycin (given 30 to 60 minutes before endoscopy to clear blood clots from the stomach view), and octreotide or terlipressin plus IV ceftriaxone if liver cirrhosis is suspected.
3. Endoscopic Hemostasis, Interventional Radiology, or Balloon Tamponade: Within 12 to 24 hours (or immediately after airway intubation in unstable patients), a gastroenterologist passes a flexible fiber-optic esophagogastroduodenoscope (EGD) down the throat to locate the bleeding vessel and seal it using metal hemoclips, thermal multipolar electrocoagulation, epinephrine injection, hemostatic powder spray (Hemospray), or elastic variceal rubber band ligation. If bleeding cannot be stopped endoscopically, interventional radiologists perform transcatheter arterial embolization (TAE) (threading a microcatheter through the femoral or radial artery to plug the bleeding branch with coils) or place a transjugular intrahepatic portosystemic shunt (TIPS) for refractory varices.

Често задавани въпроси¶

Проверени източници¶

• American College of Gastroenterology (ACG, United States): ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding (Laine et al., American Journal of Gastroenterology, 2021) and ACG Clinical Guideline: Management of Patients with Acute Lower Gastrointestinal Bleeding (Sengupta et al., 2023).
• European Society of Gastrointestinal Endoscopy (ESGE): ESGE Guideline: Endoscopic Diagnosis and Management of Nonvariceal Upper Gastrointestinal Hemorrhage (2021) and Baveno VII Consensus Workshop on Portal Hypertension and Variceal Bleeding (2022).
• National Institute for Health and Care Excellence (NICE, United Kingdom) and British Society of Gastroenterology (BSG, United Kingdom): Acute Upper Gastrointestinal Bleeding in Over 16s: Management (CG141) and BSG Multisociety Care Bundle for Early Management of Acute Upper GI Bleeding.
• American College of Surgeons (ACS, United States): Advanced Trauma Life Support (ATLS) Student Course Manual (Classification of Hemorrhagic Shock: Classes I through IV and the Lethal Triad of Hypothermia, Acidosis, and Coagulopathy).

Свързани ръководства¶

• Разпознаване на шок и управление на първа помощ
• Bleeding control: direct pressure, packing, and tourniquets
• Fainting and syncope evaluation
• Хранително отравяне, остър гастроентерит и дехидратация
• Номера за спешни случаи и международно изпращане