Haematemesis

Question 1

A 36 year old man is admitted following a haematemesis. His condition is stable and he is awaiting endoscopy. However he has a further bleed and his BP falls to 80/65 mmHg. How would you manage him?

Answer 1

Introductory
BP of 80/65, this patient is likely in hypovolaemic shock secondary to haematemesis in the setting of a likely upper GI bleed.

Provisionally, consider whether this is associated with oesophageal varices. Other causes to consider

• Ruptured peptic ulcer
• Mallory-Weiss tears
• Malignancy bleed (oesophageal, gastric
• Vascular: AV malformation, dieulafoy’s lesions, telangiectasia, aortoenteric fistula

Priorities

• Call for senior help, MERT, begin assessment taking A to E approach and institute temporising measures
• Consider and begin arrangements for definitive treatment to prevent further bleeding.

Question 2

Massive haematemesis - Initial

Answer 2

Initial

• call MERT
• Get senior help, move to resus bay if appropriate
• begin A to E assessment

A - patent, maintaining, suction for blood in airway, intubate pending GCS
B - RR, SP02 monitoring, administer supplemental 02 as required
C - 2xIVC take initial bloods [VBG, FBC, coags, LFT, G+xmatch] but initial fluid resus and activate MTP [G+xmatch] to replace like with like, request 8 units initially. Consider vasopressor support (senior input). Cease any anticoagulation +/- reverse. Administer Terlipressin if suspected oesophageal varices
D - GCS, intubate if <8
E - Exposure, further sites of bleeding

Question 3

Massive Haematemesis - history

Answer 3

History

• Review patient notes and pre-endoscopy assessment
• MIST AMPLE
• sx coffee-ground vs bright red, volume, timing, duration, associated pain? pain (SOCRATES)
• PMHx: liver failure/disease, alcohol history, recent binges?
• PSHx, meds, allergies, last meal

Question 4

Massive Haematemesis - Examination

Answer 4

Examination

• as per A to E
• secondary survey

Question 5

Massive haematemesis - Investigations

Answer 5

Investigations
Key
- upper endoscopy (diagnostic and therapeutic)
- NGT to decompress stomach contents, confirm upper GI bleed

Bloods as per A to E

Other
- CXR for air under the diaphragm

Question 6

Massive haematemesis - Management

Answer 6

Management
Definitive
- Emergent upper endoscopy with clippingg, ligation, balloon tamponade, sclerotherapy, or other methods of cautery to stop the bleeding
- exploratory laparotomy if still undetermined source of bleeding

Supportive
- NBM
- suction
- prep for scope with prokinetics (metoclopromide) as can increase visibility on scope.
- monitor for alcohol, utilise AWS
- address underlying aetiology:
   0 PUD: cease NSAIDs, start PPI
   0 alcohol: educate, counsel, AWS 
   0 variceal: ß-blockers (splanchnic vasoconstriction)