Haematemesis Flashcards
1
Q
What do you first do when you see a patient with haematemesis?
A
- Call for help
2. ABC
2
Q
What do you check in airway with haematemesis?
A
- Can they talk?
2. Gurgling or stridor?
3
Q
What should you beware of in patient with haematemesis?
A
blood in the oropharynx (use section to remove)
4
Q
What do you check with breathing and haematemesis?
A
signs of respiratory distress
5
Q
What are signs of respiratory distress?
A
- tachypnoea
- use of accessory muscles
- low sats
6
Q
What do you check with circulation with people with haematemesis?
A
- Do they have a pulse?
2. Are they in shock?
7
Q
What are signs of shock?
A
- tachycardia
- narrow pulse pressure
- hypotension
- cold peripheries
8
Q
What disabilities do you check with haematemesis?
A
- Patient GCS
2.
9
Q
What exposure do you check with haematemesis?
A
may have suffered trauma at multiple sight so check
10
Q
What is the BP measurement for shock?
A
<90/60mmHg
11
Q
If they are in shock what do they need?
A
fluid resus
12
Q
How do you start fluid resus?
A
- Apply high flow oxygen (15L/min)
2. Get IV access: insert large bore (14-16G) cannula
13
Q
What do you send bloods for?
A
- Venous blood gas
- Clotting
- Cross-match 4 units of blood
- FBC
- Urea and creatinine
- Electrolytes
- Liver enzymes, bilirubin and albumin
14
Q
What do you look for in a venous blood gas?
A
- Rapid estimate of patients Hb
2. Show lactate which will shock extent of shock
15
Q
Why do you check clotting?
A
check bleeding tendency incase needs correcting
16
Q
What does the FBC provide?
A
- accurate haemoglobin
- platelet count (low platelets contribute to bleeding)
17
Q
Why do you look for urea and creatinine?
A
is he hypovolemic and/or in acute renal failure?
18
Q
What would elevated urea indicate?
A
large GI bleed that has happen long enough to be digested and broken down into urea
19
Q
Why might you have an imbalance of electrolytes?
A
vomiting
20
Q
Why may K+ be elevated?
A
destruction of ingested rbc
21
Q
Why do you check liver enzymes, bilirubin and albumin?
A
chronic liver disease
22
Q
Why is chronic liver disease important in haematemesis?
A
oesophageal varices and therefore of haematemesis (clotting also reflects liver synthetic function)
23
Q
How do you give volume resuscitation?
A
- Give to 2L of a warmed crystalloid solution (e.g. Hartmann’s, Plasmalyte, normal saline) as 250ml aliquotes stat
- Consider 1 or 2 units of blood
24
Q
When would u give 1-2 units of blood in fluid resus?
A
only if fresh blood in DRE or still in shock despite crystalloid solution
25
What blood do u give if you don't have time cross match?
O, Rh negative blood
26
When do you give a urinary catheter?
- shocked
| - incontinent
27
When do you give a CVP and arterial line?
need HDU or ICU installment
28
What are causes of haematemesis?
1. Oesophagitis/gastritis/duodentitis
2. Bleeding peptic ulcer (gastric or duodenal)
3. Oesophageal varices
4. Mallory - Weiss Tear
5. Gastric cancer
6. Arteriovenous malformations
7. Bleeding diathesis
8. Trauma to oesophagus or stomach
9. Vascular angiodysplasia in oesophagus or stomach, Boerhaave's oesophageal perforation
10. Haemobilia
11. Aortic-enteric fistula
29
What medication do you give if you suspect varices?
1. terlipressin 1-2mg 4-6 hourly
| 2. prophylatic antibiotics
30
When would you suspect varices?
pervious endoscopy or known cirrhosis
31
What is terlipressin? What does it do?
- ADH agonist
| - causes splanchnic vasconstriction thereby reducing mesenteric blood flow and portal pressure
32
What medication do you give post endoscopy?
PPIs
33
What does score 0 on Blatchford score mean?
low risk and may be suitable for outpatient
34
What does score 6 on the blatchford score mean?
high risk and require intervention
35
What is blatchford independent of?
endoscopy findings
36
What does rockall score say?
predict risk of rebleeding and mortality in patients with upper GI haemorrhage
37
What is rockall score used as?
indicator for severity that helps guide urgency of endoscopy
38
What are the indications for emergency endoscopy?
1. unstable patients with severe acute upper GI bleeding immediately after resus
2. continuing GI bleeding or Blatchford score >6
3. recent aortic graft to exclude aortic-enteric fistula
39
What are the first line investigations to do for haematemesis?
1. OGD
2. Erect chest radiograph
3. CT scan of the chest-abdomen
40
What would haematemesis + pneumoperitoneum on xray suggest?
perforated peptic ulcer
41
What would left sided pleural effusion and haematemesis suggest?
Boerhaave's perforation
42
When do you need to require a contract CT aortogram with haematemesis?
known aortic graft (to repair aortic aneurysm) to rule out aorto-enteric fistula
43
What questions are key to ask in the history of haematemesis?
1. How much blood has the patient vomitted?
2. Character of vomit
3. Melaena or frank blood in stool?
4. Did forceful vomiting trigger the haematemesis?
5. Recent weight loss?
6. Problems swallowing?
7. Easy bruising, distended abdomen, puffy ankles, lethary?
8. Epigastric pain
44
What would fresh blood vomit suggest?
upper GI bleed
45
What would coffee ground feaces suggest?
partially digested food?
46
What would faeculent vomit suggest?
small bowel obstruction
47
What would melaena stool suggest (tarry black)
- Upper GI haemarrohage
| - Digestion of blood
48
What would Haematrochezia (frank blood stool) suggest?
1. lower GI haemorrhage
| 2. profusly bleeding Upper GI one with fast GI transit time
49
What would you be worried about if forceful vomiting triggered the haematemesis?
1. Mallory-Weiss tear
| 2. Boerhaave's performation
50
What would recent weight loss with haematemesis suggest?
upper GI malignanacy
51
What would problems swallowing with haematemesis suggest?
oesophageal malignancy
52
What would easy bruising, distended abdomen, puffy ankles, lethargy with hematemesis suggest?
liver failure (could explain bleeding tendency and/or, if liver is cirrhotic explain oesophageal varices)
53
What would gnawing epigastric pain with haematemesis suggest?
gastric carcinoma
54
What would epidosodic dyspepsia with haematemesis suggest?
GORD
55
What questions do you ask in a PMHx with haematemesis?
1. Previous upper GI haemarroge? How was it managed?
2. Heart burn or epigastric pain?
3. History of GORD?
4. Aortic repair with grafts?
5. Bleeding tendency?
6. Chronic liver disease?
56
What would you suspect with previous heatburn or epigastric pain with current? haematemesis?
1. bleeding peptic ulcer
2. bleeding oesophagitis
3. gastritis / duodenitis
57
What would a history of GORD with current haematemesis make you suspect?
- oesophagitis
- Barrett's oesophagus
- adenocarcinoma
58
Why is previous aortic repair with grafts relevant with haematemesis?
rule out aortic enteric fistula
59
Why do you ask about history of bleeding tendency with haematemesis?
clotting problem may need correcting
60
What would history chronic liver disease with current haematemesis suggest?
- bleeding tendency
| - oesophageal varices
61
What drugs do you check for in DHx?
1. Anticoagulants (warfarin, rivaroxabin)
2. NSAIDs, aspirin, clopidogrel, steroids or bisphosphonates
3. Long term methotrexate, amiodarone
4. Beta blockers
62
Why do you ask about anticoagulants with haematemesis?
can cause a clotting problem
63
What would a DHx of NSAIDs, aspirin, clopidogrel, steroids or bisphosphonates with haematemesis suggest?
peptic ulcer disease
64
What would long term methotrexate and amiodarone mean?
liver toxicity
65
Why is DHx of beta blockers important?
block signs of shock by preventing a tachycardia in a patient who is hypovolaemic
66
What questions do you ask in SHx?
1. Excessive alcohol consumption
2. Smoking
3. IV drug use, tattoos
67
What would excessive alcohol consumption with haematemesis suggest?
increase risk of cirrhosis leading to:
1. oesophageal varices
2. gastritis
3. peptic ulcer disease
68
What would a history of smoking with haematemesis suggest?
1. peptic ulcer disease
| 2. upper GI malignancy
69
Why do you ask about IV drug use and tattoos with haematemesis?
chronic viral hepatitis may lead to liver cirrohosis
70
On inspection what do you look for with a patient with haematemesis?
1. Tattoos? Needle track marks? Piercings?
2. Signs of liver disease
3. Purpura
4. Throaco-abdominal scar
5. Cachexia
71
Why do you look for tattoos and needle track marks?
chronic viral hepaptitis can lead to liver cirrohosis
72
Why can liver cirrhosis lead to haematemesis?
causing a bleeding tendency and/or oesophageal varices
73
What are signs of liver disease?
1. Jaundice
2. Scratch marks
3. Bruising
4. Spider naevi (more than 4)
5. Palmar erythema
6. Dupuytren's contracture of the palm
7. Gynaecosmastia
8. ascites
9. ankle oedema
10. caput medusa (suspect liver cirrhosis)
74
What would purpura with haematemesis suggest?
thrombocytopenia (ITP, chronic liver disease)
75
Why do you look for a thoraco-abdominal scar with haematemesis?
has had AAA repair with a graft?
76
Why do you check for cachexia with haematemesis?
malignancy
77
What do you palpate for on exam with haematemesis?
1. Hepatomegaly
2. Spenomegaly
3. Epigastric tenderness
4. 4. Epigastric mass? Supraclavicular lymphadenopathy (Virchow's node)?
78
What would hepatomegaly with haematemsis suggest?
liver disease (cirrohtic liver shrinks)
79
What would spenomegaly with haematemesis suggest?
portal hypertension (due to liver cirrhosis)
80
What would epigastric tenderness with haematemesis suggest?
1. Peptic ulcer disease
| 2. Gastritis/duodenitis
81
What would epigastric mass / Supraclavicular lymphadenopathy (Virchow's node) with haematemesis suggest?
malignancy
82
What do you check for on the DRE with haematemesis?
1. Haemorrhoids
| 2. Melaena or haematochezia
83
What would haematemsis with haemorrhoids suggest?
portal hypertension (interal haemorrhoids not palpable)
84
What would haematemsis suggest with melaena or haematochezia?
confirms GI bleed
85
What may cause macrocytic anaemia with haematemsis?
- alcohol consumption
| - vitamin B12 or folate deficiency anaemia
86
What would a raised urea but normal creatinine suggest in haematemsis?
'pre-renal uraemia' probs reflection of increased protein ingestion due to blood in GI tract
87
What clotting factors would be affected in liver disease?
II, VII, IX, X (mostly longer PT)
88
What tests could you consider with haematemesis?
1. Viral Hep and HIV serology
| 2. Urinalysis (if low albumin need to rule out proteinuri
89
How are patients waiting endoscopy for haematmesis managed?
1. Regular obs
2. Nil by mouth (6 hours prior)
3. Fluids
4. Pro-kinetic
5. If ongoing bleeding correct coagulapathy / maybe transfuse platelets
90
If the patient has alcohol abuse and potential malnourishment what is important in management?
1. thiamine
| 2. alcohol withdrawal symptoms: regular reducing dose course of chlordiazepoxide with extra doses of PRN (as required)
91
What imaging is available if endoscopy doesn't work?
1. Angiogrpahy
| 2. Lapartomy
92
What is angiography?
femoral catheter is sited and used to inject a contrast agent into coeliac axis and superior mesenteric artery - actively bleeding vessels can be visualised
93
How would you manage bleeding oesophageal varix?
1. Band ligation
2. Sclerotherapy
3. Ballon therapy
4. TIPSS
5. Laparotomy to form a portosystemic shunt
- if bleeding stopped banding to eradicate varices + follow up
- recurrent bleeding has surgical follow up
94
What is the preferred method?
endoscopic band ligation
95
Why is endoscopic sclerothherapy not used a lot?
can induce necrosis of oesophageal muscosa + less effective than banding
96
When do you use ballon tamponade?
when endoscopic band ligation not possible as blood obstructing view
97
Which procedures relive portal hypertension?
1. TIPPS
| 2. Portocaval (portosystemic shunt)
98
What is the long term management of a patient with haematemesis?
1. Lifestyle advice - stop alcohol and smoking
2. Keep BP low (propranolol or isosorbide mononitrate (especially if beta blockers contraindicated as in asthma)
3. Antibiotics - one week course for liver cirrohosis and upper GI bleeding as 50% decelop spesis
4. . TIPPS
5. Treat encephalopathy - very low protein diet and giving lactulose or enemas to decrease GI transit time and minimise GI absorption
