Chronicles of an Inner City Hospital Resident Doctor #10

Hi everyone! I'm a 2nd year resident doctor in an inner city hospital. This is a blog to document some of the experiences I encounter as a training doctor, and some of the things that I learn in the process. After all, being a physician means that I'll be learning some fascinating topics for the rest of my career, and seeing how I can use those to help patients.

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Let's get started with today's topic, inspired by some reading I did today:

Bloody vomiting and coughing

While this is a remarkably common complaint that we see among patients, it’s something I happened to be reading about today, so there’s some firsthand experience involved here as well. Now, the first thing that many people might consider when they read about bloody vomiting is tuberculosis, because it’s a hallmark symptom of this disease. However, there are many other causes that can potentially be involved (note, bloody coughs are more common in tuberculosis, but can seem like vomiting when forceful enough).

Generally, bloody vomiting/coughing stems from three areas: the upper respiratory tract (nose, mouth, throat), the lower respiratory tract (lungs and all of the branches of the bronchi that lead their way through the lung), or the gastrointestinal tract (mostly from the upper tract, which includes the mouth, esophagus, stomach, and portions of the intestines, although further portions of the intestines can be causes as well). Specifically, the causes can include infections, foreign bodies (objects that shouldn’t be there), cancers, inflammation / inflammatory diseases of the lung or gastrointestinal tract, organ failure leading to enlarged and weak blood vessels, and tunnels between organs leading to any of the three aforementioned areas. In some cases, an individual can be taking a medication or have a clotting disorder which makes them more prone to bleed, although in such a case the actual source of bleeding may still be from one of the aforementioned causes.

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There are plenty of things that we can look for, and we use a lot of history-taking in order to narrow down the possible causes and areas. This includes figuring out what conditions a person currently has, what medications they’re taking, whether they use any types of drugs or alcohol, whether they’ve had injuries of some sort, whether they’ve eaten or ingested something funky, whether they have family members who’d had similar issues or had clotting disorders, where they’ve traveled, etc.

What steps do we take to assess the causes?

Aside from the history, which does tell us a great deal of information, it’s typical to order a chest X-ray so that we can visualize a few of the most common areas from the bleed may stem. This helps us directly see whether there’s a structure inside of the chest (either in the lungs, parts of the upper respiratory tract, or upper gastrointestinal tract) that could be a cause of bleeding. Depending on what’s found, we can make a further assessment of the next steps to take.

We’d also generally take bloodwork to determine how much blood, if any, was actually lost. Sometimes we find underlying disease processes that can be masking or causing the problem, such as kidney or liver disease. Indeed, sometimes these tests can make us suspect that someone may be a chronic alcohol abuser and can be hiding this fact from us. In some cases, excessive drinking can cause vomiting so severe that it tears through the esophagus, causing bloody vomiting. That’s usually considered an emergency and can require intubation in order to prevent a person from choking on their own blood.

How do you treat the bloody vomiting?

This will depend entirely on the cause of bloody vomiting. If it stems from a lung infection, we’d usually treat the infection and suction out any secretions produced by the disease so that the patient doesn’t choke. If it stems from an injury in the gastrointestinal tract, it may be possible to perform an endoscopy-guided or colonoscopy-guided procedure where the bleed is cauterized (the bleeding tissue is destroyed) or sutured, and medications are given to reduce further bleeding. If it stems from the upper airway, it’s either due to a foreign body (which can be carefully removed) or due to an infection, which can be treated.

Of course, for all types of bleeds, especially those which are continuous, we make to continue measuring hemoglobin levels (blood levels) to tell us whether it’s relatively constant or dropping. It’ll also tell us whether there’s a sufficient or insufficient amount of clotting taking place, because that can also affect how much bleeding goes on. If too much blood or clotting factors are lost, then it’s usually advisable to give a transfusion of the pieces that are missing so that the patient does not lose circulation to their vital organs.

Among my own experiences, chronic alcoholics tend to be common harbingers of bloody vomiting. Many of them have liver failure due to their chronic alcohol use, and with liver failure comes significant problems with blood vessels that lead to various organs, including those in the gastrointestinal tract. On a nearly daily basis, we will see an alcoholic who has vomited blood due to blood vessels which have ruptured either within the esophagus or stomach. The ones with a large amount of vomiting tend to be intubated so they don’t choke on the blood, while those with small, chronic bleeds may receive an endoscopy to suture or cauterize the vessels, and further medications to prevent more bleeding. Naturally, they’re advised to stop drinking and given resources to attend addiction centers, but we’re all aware that this doesn’t stop most of them from drinking more.

In fact, when I’m in the medical intensive care unit, I’ll more than likely be seeing some alcoholics and will be able to tell you more stories about them. Stay tuned!

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I hope you've enjoyed this little snippet of a topic I learned as a resident in an inner city hospital. I'll have many more stories and learning experiences coming in the future, so stay tuned.

Sources:

1. https://lakesidemedicalcare.com/history-osteopathic-medicine/
2. COMQUESTMED (my question bank for learning information)
3. https://pocketdentistry.com/8-anatomy-and-physiology-of-respiration-and-airway-management/
4. https://www.mayoclinic.org/symptoms/vomiting-blood/basics/causes/sym-20050732
5. Me 😊

Disclaimer: this blog is for entertainment (and possibly educational) purposes only. This is not medical advice. If you have any questions or concerns about your own health, please contact a healthcare provider.

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Here are the previous editions of this blog:
Chronicles of an Inner City Hospital Resident Doctor #9
Chronicles of an Inner City Hospital Resident Doctor #8
Chronicles of an Inner City Hospital Resident Doctor #7
Chronicles of an Inner City Hospital Resident Doctor #6
Chronicles of an Inner City Hospital Resident Doctor #5
Chronicles of an Inner City Hospital Resident Doctor #4
Chronicles of an Inner City Hospital Resident Doctor #3
Chronicles of an Inner City Hospital Resident Doctor #2
Chronicles of an Inner City Hospital Resident Doctor #1