5. Haematemesis Flashcards
What does each component of the A to E response stand for?
- Airway
- breathing
- circulation
- disability (GCS scale) patient responding to pain but not voice is GCS 8
- exposure ( look for bleeding)
what is shock defined as?
how to manage shock?
- shock is defined as less than 90/60
- shock can be managed by applying high flow oxygen and gaining large bore IV access via cannula
what blood should be taken in the case of hematemesis?
- venous blood gas (shows Hb)
- clotting
- crossmatch 4 units of blood
- fBC
- urea and creatinine (kidneys? high urea shows GI bleed)
- electrolytes (due to vomiting)
- liver enzymes, bilirubin or albumin (show liver disease, oesophageal varices therefore hematomaesis
how should volume be resuscitated?
- give 2L of warmed crystalloid solution eg. Hartmanns
- consider giving 1 or 2 units of blood if there is ONGOING bleeding
What are the main differentials for haematemesis?
- Oesophagitis,
- bleeding peptic ulcer,
- oesophageal varices
- Less common causes
- mallory weiss tear,
- oesophageal cancer,
- gastric cancer,
- arteriovenous malformations
What are the Blatchford and Rockall scores?
- Blatchford- stratifies patients presenting to hospital with haematemesis into high risk and low risk (independent of endoscopy)
- Rockall- predicts the risk of rebleeding and mortality
what are the indications of an emergency endoscopy in patients with haematemesis?
- continuing upper GI bleeding
- suspicion of oesophageal varices
- initial Rockall score ≥3.
- if the patient has an aortic graft
in addition to OGD one might consider
- erect chest xray
- CT scan of chest-abdomen
What questions should you ask about the presenting complaint in a patient with haematemesis?
- How much blood?
- What was the character of the vomit?
- Any blood in the stool?
- Did vomiting trigger the haematemesis?
- Any recent weight loss or problems swallowing?
- Any signs of liver failure (bruising, distension, puffy ankles, lethargy) - suggests oesophageal varices
- Any epigastric pain?
What features in PMHx are important in a patient with haematemesis?
- Previous upper GI haemorrhage
- heartburn or epigastric pain? (maybe peptic ulcer)
- any history of GORD? (oesophagitis)
- any aortic repair with grafts? (aorto enteric fistula)
- bleeding tendency?
- chronic liver disease? (oesophageal varices)
What drugs are important to ask about in a patient with haematemesis?
- Anticoagulants
- regular NSAIDs aspirin clopidogrel steroids bisphosphonates (peptic ulcer disease)
- Drugs causing liver toxicity- methotrexate, amiodarone
- beta-blockers might mask tachycardia
important social history for Haematemesis?
- alcohol consumption ( liver disease -> oesophageal varices, gastritis, and peptic ulcer disease)
- smoking (peptic ulcers and malignancy)
- IV drug use (hepatitis leading to cirrohsis)
What are signs of liver disease?
jaundice, scratch marks, bruising, spider naevi, palmar erythema, dupuytren’s contracture, gynaecomastia, ascites, ankle oedema, caput medusa
on examination what are you looking for in Haematemesis?
- tattoos (chronic viral hepatitis)
- signs of liver disease - jaundice, scratch marks, bruising, spider naevi, Dupuytren’s contracture of the palm, gynaecomastia, ascites, ankle oedema, caput medusae?
- purpura - thrombocytopaenia
- thoracoabdominal scar - (AAA) repair with a graft
- cachexia - malignancy
on abdominal palpation what are you looking for?
- hepatomegaly (liver disease)
- splenomegaly (portal hypertension)
- epigastric tenderness (peptic ulcer disease)
- epigastric mass/virchows node (malignancy)
what might be observed with a digital rectum examination?
- haemorrhoids (portal hypertension)
- melaena OR haematochezia (this confirms GI bleed)
- melaena refers to upper GI bleeding and haematochezia refers to lower GI bleeding
what blood results might indicate liver disease?
- macrocytic anemia
- low albumin
- raised liver enzymes
- raised bilirubin
- raised GGT
- prolonged clotting times
- raised urea
how should a patient be managed whilst waiting for endoscopy?
- regular observation
- nil by mouth (endoscopy)
- fluids
- prokinetic (helps to empty the stomach)
- consider correcting platelets
- thiamine to prevent Wernicke’s encephalopathy
- monitoring for alcohol withdrawal symptoms
alternative imaging to endoscopies?
- Angiography - femoral catheter used and contrast is delivered to the coeliac axis and superior mesenteric artery
- Laparotomy
how might a bleeding oesophageal varix be managed?
- endoscopic band ligation
- endoscopic sclerotherapy
- balloon tamponade
- TIPS
- portocaval shunt
potential long term management options for portal hypertension?
- lifestyle advice (stop drinking and smoking)
- keeping blood pressure low (prevents rebleeding)
- antibiotics (prevents sepsis)
- TIPS
- treating encephalopathy
which nosebleeds are more dangerous and more prone to haematemesis?
- posterior nosebleeds from branches of the sphenopalatine artery
- anterior nosebleeds are less likely
what is a mallory-weiss tear?
what is boerhaaves perforation?
- A Mallory-Weiss tear is a tear of the tissue of your lower esophagus caused by violent coughing or vomiting
- Boerhaave’s syndrome is a rare but potentially fatal condition characterized by a transmural tear of the distal esophagus induced by a sudden increase in pressure
