Last reviewed: June 2020
Last updated: March  2018



History and exam

Other diagnostic factors

  • light-headedness/dizziness
  • postural/orthostatic hypotension
  • dysphagia
  • odynophagia
  • pain
  • melaena
  • haematochezia
  • shock
  • signs of anaemia

Risk factors

  • condition predisposing to retching, vomiting, and/or straining
  • chronic cough
  • hiatal hernia
  • retching during endoscopy or other instrumentation
  • significant alcohol use
  • previous instrumentation
  • age 30 to 50 years
  • male sex
  • aspirin or other NSAIDs ingestion
  • hiccups
  • blunt abdominal trauma
  • cardiopulmonary resuscitation
  • primal scream therapy

Diagnostic investigations

1st investigations to order

  • Full blood count (FBC)
  • urea
  • liver function test
  • Prothrombin time/International normalized ratio (PT/INR)
  • Partial thromboplastin time (PTT)
  • Chest x-ray (CXR)
  • oesophagogastroduodenoscopy
  • cross-matching/blood grouping
More 1st investigations to order

Investigations to consider

  • creatinine kinase
  • creatinine kinase-MB
  • troponin
  • ECG
  • angiography
More investigations to consider

Treatment algorithm


Professor of Medicine

Division of Gastroenterology

Department of Internal Medicine

Huntsman Cancer Institute

University of Utah

Salt Lake City



DGA declares that he has no competing interests.

Dr Douglas Adler would like to gratefully acknowledge Dr Shilpa Reddy and Dr Juan Carlos Munoz, the previous contributors to this topic. SR and JCM declare that they have no competing interests.

Peer reviewersVIEW ALL

Professor of Medicine

Department of Medicine and Therapeutics


Institute of Digestive Disease

The Chinese University of Hong Kong

Hong Kong


JS declares that he has no competing interests.

Consultant Gastroenterologist

Sandwell General Hospital


West Bromwich



IM declares that he has no competing interests.

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