bubble_chart Concept

Hematemesis refers to bleeding from the stomach or esophagus, which is expelled through the mouth, often mixed with food residues.

Suwen and Lingshu refer to it as hematemesis. The "Jingui" also refers to it as hematemesis. In the Ming Dynasty, Yixue Rumen further distinguished it as "silent expulsion in basins, called vomiting; noisy expulsion in bowls, called retching," but this distinction holds no practical significance. Later, some physicians conflated expectoration of blood with hematemesis, which is even more inappropriate. This is because hematemesis (hematemesis) involves blood originating from the stomach or esophagus, whereas expectoration of blood involves blood from the lungs or trachea. Hematemesis involves blood being expelled with vomit, often in large quantities, described as "basins" or "bowls," and is accompanied by symptoms of stomach qi ascending counterflow vomiting. On the other hand, expectoration of blood involves blood mixed with phlegm, accompanied by symptoms of lung qi ascending counterflow cough. The concepts of coughing and vomiting are different and can be distinguished; they should not be conflated simply because both involve blood being expelled from the mouth.

bubble_chart Pattern Analysis

1. Stomach Heat︰Sudden hematemesis, with a large amount of bright red or purplish-red blood mixed with food residues, is often preceded by irritability, thirst, a sensation of heat rising from the epigastrium, or epigastric pain, or chest and gastric stuffiness, epigastric upset with acid regurgitation, or triggered after alcohol or food consumption. There may be severe constipation or difficult bowel movements with black, tar-like stools, dark-colored urine, red lips, fetid mouth odor, a red tongue with a yellow and thick coating, and a slippery, rapid pulse. This condition is often caused by habitual alcohol consumption or indulgence in spicy, fried, or greasy foods, leading to heat accumulation in the stomach. Alcohol-induced heat damages the stomach, exacerbating fire and stirring blood; or external summerheat injury disturbing the nutrient-blood level, both of which can result in accumulated heat transforming into fire and forcing reckless blood flow. Prominent symptoms of Yangming excess fire (such as extreme thirst, fetid mouth odor, constipation, slippery and rapid pulse, etc.) are evident. The primary treatment involves clearing stomach heat, cooling blood, and stopping bleeding, using Sanhuang Xiexin Decoction combined with Four Fresh Ingredients Pill as the main remedies.
2. Liver Fire Invading the Stomach︰Hematemesis accompanied by irritability, chest tightness, frequent anger, hypochondriac pain, bitter taste in mouth or sour taste in mouth, frequent nightmares, or bluish lips, or recurrent hiccups, red tongue texture, yellow coating, and wiry-rapid pulse. It is mostly caused by depression and anger damaging the liver, liver qi transversely counterflowing, stagnating and transforming into fire, scorching the stomach collaterals; or preexisting stomach heat compounded by liver depression, with stagnant fire in the liver channel exacerbating stomach heat, forcing blood to recklessly move, all of which can lead to hematemesis. Suwen.Jutong Lun states, "Anger causes qi counterflow, and in severe cases leads to hematemesis," referring precisely to this syndrome. The main distinguishing features of these two syndromes are: the characteristics of liver-gallbladder excess fire (bitter taste in mouth, sour taste in mouth, wiry-rapid pulse) and liver qi transversely counterflowing (chest tightness, hypochondriac pain, bluish lips, audible hiccups). The treatment principle focuses on clearing the liver and cooling blood, subduing the liver and descending counterflow, with the formula Zhang Xi-chun's Xigan Jiangwei Decoction used as the main prescription.
3. Stomach Blood Stasis︰Hematemesis with dark purple blood containing clots, accompanied by stabbing pain in the epigastrium, fixed pain location, tenderness, dark complexion, thirst with water in the mouth but no desire to swallow, purplish tongue, and wiry-choppy pulse. This is similar to hematemesis caused by stomach heat exuberance or liver fire invading the stomach, both of which are excess-pattern hematemesis. However, blood stasis hematemesis lacks heat signs. Blood stasis hematemesis may present with thirst, as mentioned in the Treatise on Blood Stasis·Chapter on Static Blood: "When static blood is internally present, it causes thirst. The reason is that blood and qi are inherently inseparable. When static blood accumulates internally, it obstructs the flow, preventing the upward movement of fluids, thus resulting in thirst, termed 'blood thirst.' Once the static blood is resolved, the thirst ceases." This type of thirst due to static blood is not caused by heat damaging fluids but rather by static blood obstructing the collaterals, preventing fluids from ascending. It differs from the thirst with strong desire to drink seen in stomach heat exuberance, manifesting instead as "taking water in the mouth but with no desire to swallow." The causes of blood stasis hematemesis often include trauma, internal bleeding, or blood failing to circulate properly, stagnating at the site of meridian injury, frequently leading to hematemesis. The Treatise on Blood Stasis·Chapter on Hematemesis states: "Wherever stasis exists, it invariably obstructs the qi pathway and impedes qi movement." When qi movement is obstructed, qi counterflow arises, causing static blood to recklessly surge upward and spill outward, resulting in hematemesis. Alternatively, excessive use of cold-cooling herbs in treating excess-heat-pattern hematemesis (such as stomach heat or liver fire) may lead to blood coagulation and stasis obstructing the collaterals. Other causes include qi deficiency with blood stasis or yang deficiency with blood cold, all of which can contribute to blood stasis. The clinical features of blood stasis hematemesis include: dark purple blood with clots, often accompanied by stabbing epigastric pain, fixed and tender pain location, dull complexion, purplish tongue, and choppy pulse. Treatment focuses on invigorating blood and resolving stasis, stopping bleeding, and downbearing counterflow. The formula used is the Stasis-Resolving Hemostasis Decoction.
4. Yin Deficiency︰Hematemesis recurs persistently, with bright red color and large volume, often accompanied by vexing heat in the chest, palms, and soles, dry mouth and desire to drink, lack of strength, emaciation, flushed face and restlessness, insomnia, dreamfulness, a red tongue with scant coating, and a thin, rapid pulse. It often presents clinical features of kidney yin deficiency, such as tidal fever, night sweats, soreness in the waist, tinnitus, weak chi pulse, nocturnal emission, a red tongue without coating, etc. The key points for differentiation lie particularly in the tongue coating, pulse manifestation, and disease course. The treatment principle is to nourish water and subdue fire, using the Six-Ingredient Rehmannia Decoction supplemented with Donkey-hide Gelatin and child’s urine. When clearing and descending, excessive use of cold and cooling herbs should be avoided to protect yin. Commonly selected herbs include Scrophularia Root, Ophiopogon Tuber, Lotus Root Juice, Lalang Grass Rhizome, raw Platycladus juice, and antelope horn, which clear and descend without damaging yin. Additionally, during treatment, attention should be paid to the influence of seasonal changes on the rising movement of yang qi in the body. As stated in *Wang Xugao’s Medical Records: Hematemesis Case*: "At the time of the Spring Equinox (the 4th solar term), yang qi surges vigorously. Blood patterns at this time may slightly stabilize before flaring up again. This is because the liver yang in the body responds to the rising yang qi of the season without restraint, leading to sudden severe vomiting. It is urgent to nourish yin while clearing and descending, but caution is needed to avoid further damaging yin as fire is subdued."
5. Insufficiency of the Heart and Spleen︰Persistent hematemesis with pale and dull-colored blood, dull epigastric pain relieved by pressure, pallid complexion, shortness of breath and timidity, weakness of the limbs, palpitations due to fright and insomnia, loss of appetite, occasional black stools, or abdominal distension and fullness with loose stools, pale lips, pale tongue with scant coating, deep and thin or thin and rough pulse. This is often caused by excessive contemplation injuring the spleen; or overexertion and insomnia damaging the heart and spleen; or persistent vomiting severely impairing stomach qi. The spleen governs blood control, and spleen qi deficiency leads to failure in controlling blood. The heart governs blood and vessels, and heart qi deficiency results in loss of blood governance, thus leading to hematemesis. The condition develops gradually due to prolonged illness; or it may occur in individuals with constitutional yang deficiency or excessive sexual overexertion, damaging spleen and kidney yang. Yang deficiency leads to failure in blood control, hence hematemesis may occur. The clinical manifestations of hematemesis due to spleen qi deficiency failing to control blood and hematemesis due to spleen-kidney yang deficiency are very similar. The distinguishing features are: the former primarily presents with qi deficiency symptoms such as shortness of breath, timidity, limb fatigue, and loose stools; while the latter, in addition to these, also exhibits signs of yang deficiency such as aversion to cold, cold limbs, clear and profuse urine, and slow pulse. If yang decline reaches an extreme, with severe internal cold and repelled yang floating upward, symptoms like flushed face, panting, restlessness, and faint pulses may appear, indicating a repelled yang pattern of deficiency-fire. The former is treated primarily by regulating the spleen to control blood and tonifying spleen qi, using Returning to Spleen Decoction.
6. Spleen-kidney Yang Deficiency︰Recurrent hematemesis with a prolonged course, dark-colored blood, accompanied by pale complexion, weak breathing, cold limbs, fear of cold, drowsiness, loose stools, clear and profuse urine, pale tongue texture with thin white and slippery coating, deep faint and slow or moderate pulse. In severe cases, flushed face like makeup, panting, restlessness, but with six pulse conditions being faint and fine, and reversal cold of limbs. This is often due to the need for warming and tonifying the spleen and kidney, consolidating yang to control bleeding. Commonly used Oven Yellow Earth Decoction with modifications.

Yin deficiency with effulgent fire hematemesis, stomach fire, and liver fire all share the mechanism of disease where heat forces blood to move, but one is due to deficient fire and the other to excess fire, with different deficiency and excess symptoms and signs. Deficiency pattern often have a long course and are characterized by repeated occurrences, while excess pattern are usually sudden, intense, and short-lived. Deficiency pattern may also arise from repeated episodes of excess pattern hematemesis, or from overexertion damaging the kidneys, excessive indulgence in alcohol and sex, injuring essence and blood, leading to yin deficiency and fire agitation, with deficient fire rising and qi rebelling, causing blood to recklessly follow the deficient fire and rebellious qi, resulting in hematemesis. As Mingyi Zazhu states: "In the human body, yin is often insufficient, while yang is often excessive. Moreover, few practice moderation in desires, and many indulge excessively. When essence and blood are depleted, ministerial fire will inevitably flourish. When fire flourishes, yin is further consumed, ... leading to symptoms such as hematemesis." In treatment, stomach fire and liver fire, being excess fire, can be directly subdued with cold and cooling methods, while yin deficiency with effulgent fire hematemesis, being rootless deficient fire, should not be directly subdued but treated by nourishing water to reduce fire.

Hematemesis, whether due to intense stomach heat or liver fire attacking the stomach, presents with bright red or purplish-red blood, which is not significantly different from the blood color in yin deficiency with effulgent fire hematemesis. The distinction lies in the former having a short course and often being sudden and intense, while the latter has a long course and is characterized by repeated occurrences. Combined with other clinical manifestations, they can be differentiated. Spleen deficiency hematemesis and yang deficiency hematemesis present with pale and dull blood, respectively, and their clinical manifestations are distinctly different from excess heat pattern, making them easy to differentiate. Spleen deficiency hematemesis has pale blood, while yang deficiency hematemesis has dull blood, which can also be distinguished. Blood stasis hematemesis, with purplish-black blood and static blood clots, differs from other types of bleeding.

bubble_chart Documentation

1. Suwen-Zhizhenyao Da Lun: "taiyang celestial control，cold evil element being restricted，…blood changes within…people suffer from precordial pain、hematemesis、bloody diarrhea、nosebleed."
2. Lingshu-Yuban: "hematemesis with chest fullness extending to the back，pulse small and rapid indicating rebellion."