5. Haematemesis

Question 1

Describe the immediate management of a patient who has lost a lot of blood.

Answer 1

ABCDE

Question 2

What landmark defines the terms ‘upper GI’ and ‘lower GI’?

Answer 2

The ligament of trietz (this is towards the distal end of the duodenum)

Question 3

List the differential diagnosis for haematemesis.

Answer 3

Oesophagitis/gastritis/duodenitis
Bleeding peptic ulcer 
Oesophageal varices 
Mallory-Weiss tear 
Gastric cancer
Oesophageal cancer 
Arteriovenous malformation

Question 4

Describe two additional components in the management of upper GI bleeds that are caused by oesophageal varices.

Answer 4

Terlipressin 1-2 mg, 4-6 hourly

Prophylactic antibiotics

Question 5

Describe the two scoring systems for upper GI bleeds.

Answer 5

Glasgow-Blatchford – stratifies patients presenting with upper GI bleeds into low and high-risk categories. It is independent of endoscopy.
Rockall – involves a more comprehensive assessment of haematemesis. It is used to predict risk of re-bleeding and mortality. Based on age, shock, comorbidities and endoscopy findings.

Question 6

When is emergency endoscopy indicated?

Answer 6

Unstable patient with severe acute upper GI bleeding immediately after resuscitation
Suspicion of ongoing upper GI bleed and Glasgow-Blatchford > 6
Patients with a previous aortic graft to exclude aorto-enteric fistula

Question 7

Other than OGD, list two other useful investigations for upper GI bleeds.

Answer 7

Erect CXR

• Perforated peptic ulcer may cause haematemesis and pneumoperitoneum
• A left-sided pleural effusion may be seen in Boerhaave’s perforation

CT Chest/Abdomen

Question 8

Which investigation does all patients with aortic grafts need?

Answer 8

Contrast CT aortogram to rule out aorto-enteric fistula

Question 9

List some questions that are important to ask patients presenting with upper GI bleeds.

Answer 9

How much blood was there?
What did the blood look like? (Fresh or coffee grounds)
Has there been any blood in the stool?
Did vomiting trigger the haematemesis?
Has there been any recent weight loss? (malignancy)
Have you had any problems swallowing? (oesophageal malignancy)
Have you experienced easy bruising, abdominal distension, puffy ankles or lethargy? (liver failure)
Has there been any epigastric pain?

Question 10

Why is it important to ask about the character of the blood?

Answer 10

Fresh blood suggests upper GI bleed

Coffee grounds vomit suggests that the blood has been partially digested by stomach acids

Question 11

What is the difference between melaena and haematochezia?

Answer 11

Melaena – caused by upper GI bleeds and digestion of the blood during GI transit
Haematochezia – fresh blood in stools (Usually caused by lower GI haemorrhage or by profuse upper GI bleed or if GI transit times are rapid)

Question 12

Melaena – caused by upper GI bleeds and digestion of the blood during GI transit
Haematochezia – fresh blood in stools
Usually caused by lower GI haemorrhage or by profuse upper GI bleed or if GI transit times are rapid

Answer 12

Forceful vomiting can cause Mallory-Weiss tears and Boerhaave’s perforation, which lead to haematemesis

Question 13

List some key features that you should look out for in the past medical history.

Answer 13

Previous upper GI haemorrhage
Heartburn or epigastric pain (may suggest peptic ulcer disease or oesophagitis/gastritis/duodenitis)
History of GORD (can lead to oesophageal cancer)
Aortic repair with grafts
Bleeding tendency
Chronic liver disease

Question 14

List some key features that you should look out for in the drug history.

Answer 14

Anticoagulants
Drugs that increase risk of PUD (e.g. NSAIDs, aspirin, bisphosphonates, steroids)
Drugs that cause liver toxicity (e.g. methotrexate, amiodarone)
Beta-blockers (can mask signs of shock)

Question 15

List some key features that you should look out for in the social history.

Answer 15

Excessive alcohol consumption (risk of cirrhosis and PUD)
Smoking (risk of PUD and GI malignancy)
IV drug use and tattoos (risk of viral hepatitis)

Question 16

Why is it important to take note of any needle track marks and piercings on physical examination?

Answer 16

They are both risk factors for viral hepatitis

Question 17

List some signs of liver disease on examination.

Answer 17

Jaundice 
Scratch marks 
Spider naevi
Bruising 
Palmar erythema
 Dupuytren’s contracture 
Gynaecomastia 
Ascites 
Ankle oedema

Question 18

What does purpura suggest?

Answer 18

Thrombocytopenia

Question 19

List some significant signs that could be found on palpation and state what they suggest.

Answer 19

Hepatomegaly – can occur in liver disease
Splenomegaly – can be a sign of portal hypertension
Epigastric tenderness – can suggest PUD or gastritis/duodenitis
Virchow’s lymphadenopathy – suggests GI malignancy

Question 20

List some significant signs that could be found on DRE and state what they suggest.

Answer 20

Haemorrhoids – could be a consequence of portal hypertension
Melaena or haematochezia – confirms GI bleed

Question 21

List some features of liver disease in the blood results.

Answer 21

Macrocytic anaemia 
Low albumin
Raised liver enzymes 
Raised bilirubin 
Raised GGT 
Prolonged clotting times 
Raised urea

Question 22

List some causes of macrocytic anaemia.

Answer 22

B12 deficiency
Folate deficiency
Alcoholism

Question 23

List some causes of low albumin.

Answer 23

Chronic liver failure
Malnutrition
Malabsorption
Nephrotic syndrome

Question 24

What derangement of the liver function tests is consistent with alcohol abuse?

Answer 24

Raised GGT in the absence of raised ALP

Question 25

What does raised urea in the context of normal renal function suggest?

Answer 25

It suggests that the patient has had a ‘protein meal’ of some form – which is most likely to be due to the digesting of red blood cells

Question 26

What other investigations may be useful in patients with upper GI bleeds?

Answer 26

Viral hepatitis and HIV serology

Urinalysis (may show proteinuria, which, in the context of hypoalbuminaemia, would suggest nephrotic syndrome)

Question 27

Describe the management of a patient awaiting endoscopy.

Answer 27

Regular observation 
NBM
IV fluids 
Pro-kinetic drugs (e.g. erythromycin, metoclopramide) 1 hour before endoscopy 
Correct coagulopathy/platelets

Question 28

State two important complications of alcoholism that you must bear in mind when taking care of an alcoholic patient.

Answer 28

Thiamine – prevents Wernicke-Korsakoff syndrome

Withdrawal – prescribe chlordiazepoxide

Question 29

Other than endoscopy, list two other ways of visualising a bleed.

Answer 29

Angiography

Laparotomy

Question 30

List three methods of stopping the bleeding from oesophageal varices.

Answer 30

Endoscopic band ligation 
Injection sclerotherapy 
Balloon tamponade (Sengstaken-Blakemore tube or Minnesota tube)

Question 31

State and describe a surgical technique used to relieve portal hypertension.

Answer 31

Transjugular intrahepatic portosystemic shunt (TIPS)

NOTE: this is an intrahepatic connection between the portal vein and the hepatic vein

Question 32

Describe an important complication of portacaval shunting.

Answer 32

It can trigger hepatic encephalopathy because toxins are bypassing the liver and entering the systemic circulation

Question 33

Briefly describe the long-term management of portal hypertension.

Answer 33

Lifestyle: stop drinking alcohol and smoking 
Maintain low blood pressure 
Antibiotics 
TIPS
Treat hepatic encephalopathy

Question 34

What is commonly used to treat hepatic encephalopathy?

Answer 34

Lactulose and phosphate enemas

They decrease GI transit time and minimise GI absorption

Question 35

Which type of nosebleed can present with haematemesis?

Answer 35

Posterior nose bleeds