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