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Z Year3 Clinical Presentations > Haematemesis > Flashcards

Haematemesis Flashcards

1
Q

What do you first do when you see a patient with haematemesis?

A
  1. Call for help

2. ABC

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2
Q

What do you check in airway with haematemesis?

A
  1. Can they talk?

2. Gurgling or stridor?

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3
Q

What should you beware of in patient with haematemesis?

A

blood in the oropharynx (use section to remove)

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4
Q

What do you check with breathing and haematemesis?

A

signs of respiratory distress

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5
Q

What are signs of respiratory distress?

A
  • tachypnoea
  • use of accessory muscles
  • low sats
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6
Q

What do you check with circulation with people with haematemesis?

A
  1. Do they have a pulse?

2. Are they in shock?

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7
Q

What are signs of shock?

A
  1. tachycardia
  2. narrow pulse pressure
  3. hypotension
  4. cold peripheries
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8
Q

What disabilities do you check with haematemesis?

A
  1. Patient GCS

2.

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9
Q

What exposure do you check with haematemesis?

A

may have suffered trauma at multiple sight so check

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10
Q

What is the BP measurement for shock?

A

<90/60mmHg

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11
Q

If they are in shock what do they need?

A

fluid resus

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12
Q

How do you start fluid resus?

A
  1. Apply high flow oxygen (15L/min)

2. Get IV access: insert large bore (14-16G) cannula

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13
Q

What do you send bloods for?

A
  1. Venous blood gas
  2. Clotting
  3. Cross-match 4 units of blood
  4. FBC
  5. Urea and creatinine
  6. Electrolytes
  7. Liver enzymes, bilirubin and albumin
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14
Q

What do you look for in a venous blood gas?

A
  1. Rapid estimate of patients Hb

2. Show lactate which will shock extent of shock

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15
Q

Why do you check clotting?

A

check bleeding tendency incase needs correcting

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16
Q

What does the FBC provide?

A
  • accurate haemoglobin

- platelet count (low platelets contribute to bleeding)

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17
Q

Why do you look for urea and creatinine?

A

is he hypovolemic and/or in acute renal failure?

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18
Q

What would elevated urea indicate?

A

large GI bleed that has happen long enough to be digested and broken down into urea

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19
Q

Why might you have an imbalance of electrolytes?

A

vomiting

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20
Q

Why may K+ be elevated?

A

destruction of ingested rbc

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21
Q

Why do you check liver enzymes, bilirubin and albumin?

A

chronic liver disease

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22
Q

Why is chronic liver disease important in haematemesis?

A

oesophageal varices and therefore of haematemesis (clotting also reflects liver synthetic function)

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23
Q

How do you give volume resuscitation?

A
  1. Give to 2L of a warmed crystalloid solution (e.g. Hartmann’s, Plasmalyte, normal saline) as 250ml aliquotes stat
  2. Consider 1 or 2 units of blood
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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

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25
Q

What blood do u give if you don’t have time cross match?

A

O, Rh negative blood

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26
Q

When do you give a urinary catheter?

A
  • shocked

- incontinent

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27
Q

When do you give a CVP and arterial line?

A

need HDU or ICU installment

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28
Q

What are causes of haematemesis?

A
  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
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29
Q

What medication do you give if you suspect varices?

A
  1. terlipressin 1-2mg 4-6 hourly

2. prophylatic antibiotics

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30
Q

When would you suspect varices?

A

pervious endoscopy or known cirrhosis

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31
Q

What is terlipressin? What does it do?

A
  • ADH agonist

- causes splanchnic vasconstriction thereby reducing mesenteric blood flow and portal pressure

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32
Q

What medication do you give post endoscopy?

A

PPIs

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33
Q

What does score 0 on Blatchford score mean?

A

low risk and may be suitable for outpatient

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34
Q

What does score 6 on the blatchford score mean?

A

high risk and require intervention

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35
Q

What is blatchford independent of?

A

endoscopy findings

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36
Q

What does rockall score say?

A

predict risk of rebleeding and mortality in patients with upper GI haemorrhage

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37
Q

What is rockall score used as?

A

indicator for severity that helps guide urgency of endoscopy

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38
Q

What are the indications for emergency endoscopy?

A
  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
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39
Q

What are the first line investigations to do for haematemesis?

A
  1. OGD
  2. Erect chest radiograph
  3. CT scan of the chest-abdomen
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40
Q

What would haematemesis + pneumoperitoneum on xray suggest?

A

perforated peptic ulcer

41
Q

What would left sided pleural effusion and haematemesis suggest?

A

Boerhaave’s perforation

42
Q

When do you need to require a contract CT aortogram with haematemesis?

A

known aortic graft (to repair aortic aneurysm) to rule out aorto-enteric fistula

43
Q

What questions are key to ask in the history of haematemesis?

A
  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
Q

What would fresh blood vomit suggest?

A

upper GI bleed

45
Q

What would coffee ground feaces suggest?

A

partially digested food?

46
Q

What would faeculent vomit suggest?

A

small bowel obstruction

47
Q

What would melaena stool suggest (tarry black)

A
  • Upper GI haemarrohage

- Digestion of blood

48
Q

What would Haematrochezia (frank blood stool) suggest?

A
  1. lower GI haemorrhage

2. profusly bleeding Upper GI one with fast GI transit time

49
Q

What would you be worried about if forceful vomiting triggered the haematemesis?

A
  1. Mallory-Weiss tear

2. Boerhaave’s performation

50
Q

What would recent weight loss with haematemesis suggest?

A

upper GI malignanacy

51
Q

What would problems swallowing with haematemesis suggest?

A

oesophageal malignancy

52
Q

What would easy bruising, distended abdomen, puffy ankles, lethargy with hematemesis suggest?

A

liver failure (could explain bleeding tendency and/or, if liver is cirrhotic explain oesophageal varices)

53
Q

What would gnawing epigastric pain with haematemesis suggest?

A

gastric carcinoma

54
Q

What would epidosodic dyspepsia with haematemesis suggest?

A

GORD

55
Q

What questions do you ask in a PMHx with haematemesis?

A
  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
Q

What would you suspect with previous heatburn or epigastric pain with current? haematemesis?

A
  1. bleeding peptic ulcer
  2. bleeding oesophagitis
  3. gastritis / duodenitis
57
Q

What would a history of GORD with current haematemesis make you suspect?

A
  • oesophagitis
  • Barrett’s oesophagus
  • adenocarcinoma
58
Q

Why is previous aortic repair with grafts relevant with haematemesis?

A

rule out aortic enteric fistula

59
Q

Why do you ask about history of bleeding tendency with haematemesis?

A

clotting problem may need correcting

60
Q

What would history chronic liver disease with current haematemesis suggest?

A
  • bleeding tendency

- oesophageal varices

61
Q

What drugs do you check for in DHx?

A
  1. Anticoagulants (warfarin, rivaroxabin)
  2. NSAIDs, aspirin, clopidogrel, steroids or bisphosphonates
  3. Long term methotrexate, amiodarone
  4. Beta blockers
62
Q

Why do you ask about anticoagulants with haematemesis?

A

can cause a clotting problem

63
Q

What would a DHx of NSAIDs, aspirin, clopidogrel, steroids or bisphosphonates with haematemesis suggest?

A

peptic ulcer disease

64
Q

What would long term methotrexate and amiodarone mean?

A

liver toxicity

65
Q

Why is DHx of beta blockers important?

A

block signs of shock by preventing a tachycardia in a patient who is hypovolaemic

66
Q

What questions do you ask in SHx?

A
  1. Excessive alcohol consumption
  2. Smoking
  3. IV drug use, tattoos
67
Q

What would excessive alcohol consumption with haematemesis suggest?

A

increase risk of cirrhosis leading to:

  1. oesophageal varices
  2. gastritis
  3. peptic ulcer disease
68
Q

What would a history of smoking with haematemesis suggest?

A
  1. peptic ulcer disease

2. upper GI malignancy

69
Q

Why do you ask about IV drug use and tattoos with haematemesis?

A

chronic viral hepatitis may lead to liver cirrohosis

70
Q

On inspection what do you look for with a patient with haematemesis?

A
  1. Tattoos? Needle track marks? Piercings?
  2. Signs of liver disease
  3. Purpura
  4. Throaco-abdominal scar
  5. Cachexia
71
Q

Why do you look for tattoos and needle track marks?

A

chronic viral hepaptitis can lead to liver cirrohosis

72
Q

Why can liver cirrhosis lead to haematemesis?

A

causing a bleeding tendency and/or oesophageal varices

73
Q

What are signs of liver disease?

A
  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
Q

What would purpura with haematemesis suggest?

A

thrombocytopenia (ITP, chronic liver disease)

75
Q

Why do you look for a thoraco-abdominal scar with haematemesis?

A

has had AAA repair with a graft?

76
Q

Why do you check for cachexia with haematemesis?

A

malignancy

77
Q

What do you palpate for on exam with haematemesis?

A
  1. Hepatomegaly
  2. Spenomegaly
  3. Epigastric tenderness
    1. Epigastric mass? Supraclavicular lymphadenopathy (Virchow’s node)?
78
Q

What would hepatomegaly with haematemsis suggest?

A

liver disease (cirrohtic liver shrinks)

79
Q

What would spenomegaly with haematemesis suggest?

A

portal hypertension (due to liver cirrhosis)

80
Q

What would epigastric tenderness with haematemesis suggest?

A
  1. Peptic ulcer disease

2. Gastritis/duodenitis

81
Q

What would epigastric mass / Supraclavicular lymphadenopathy (Virchow’s node) with haematemesis suggest?

A

malignancy

82
Q

What do you check for on the DRE with haematemesis?

A
  1. Haemorrhoids

2. Melaena or haematochezia

83
Q

What would haematemsis with haemorrhoids suggest?

A

portal hypertension (interal haemorrhoids not palpable)

84
Q

What would haematemsis suggest with melaena or haematochezia?

A

confirms GI bleed

85
Q

What may cause macrocytic anaemia with haematemsis?

A
  • alcohol consumption

- vitamin B12 or folate deficiency anaemia

86
Q

What would a raised urea but normal creatinine suggest in haematemsis?

A

‘pre-renal uraemia’ probs reflection of increased protein ingestion due to blood in GI tract

87
Q

What clotting factors would be affected in liver disease?

A

II, VII, IX, X (mostly longer PT)

88
Q

What tests could you consider with haematemesis?

A
  1. Viral Hep and HIV serology

2. Urinalysis (if low albumin need to rule out proteinuri

89
Q

How are patients waiting endoscopy for haematmesis managed?

A
  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
Q

If the patient has alcohol abuse and potential malnourishment what is important in management?

A
  1. thiamine

2. alcohol withdrawal symptoms: regular reducing dose course of chlordiazepoxide with extra doses of PRN (as required)

91
Q

What imaging is available if endoscopy doesn’t work?

A
  1. Angiogrpahy

2. Lapartomy

92
Q

What is angiography?

A

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
Q

How would you manage bleeding oesophageal varix?

A
  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
Q

What is the preferred method?

A

endoscopic band ligation

95
Q

Why is endoscopic sclerothherapy not used a lot?

A

can induce necrosis of oesophageal muscosa + less effective than banding

96
Q

When do you use ballon tamponade?

A

when endoscopic band ligation not possible as blood obstructing view

97
Q

Which procedures relive portal hypertension?

A
  1. TIPPS

2. Portocaval (portosystemic shunt)

98
Q

What is the long term management of a patient with haematemesis?

A
  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

Z Year3 Clinical Presentations (37 decks)

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