Haematemesis

Question 1

A 25 year old man presents with haematemesis after binge drinking. How would you assess him?

Answer 1

Impression
Haematemesis, concerned about recurrent bleeding and risk of hypovolaemic shock.

DDx to consider;

• Oesophageal: varices, mallory weiss tears, oesophagi’s
• Gastric: PUD +/- rupture, aortoenteric fistula, AV malformations, dieulafoy lesions
• Other: malignancy and secondary bleed

Goals

• Call for senior help, A to E to ensure HD stability and institute appropriate emergent management
• appropriate dispositioning for gastro/retrieval depending on status

Question 2

Haematemesis - Assessment

Answer 2

Assessment
A - patent, maintaining. suction for blood/vomitus, consider adjuncts/intubation if HD not able to maintain pending GCS
B - RR, SP02, supplemental as required. Resp examination, crackles may be suggestive of aspiration
C - BP/HR monitoring. IV access for initial bloods: VBG, FBC, UEC, CRP/ESR, LFT, G+H if significant or ongoing haematemesis
D - GCS
E - temp, other sites of injury in setting of alcohol binge

Question 3

Haematemesis - History

Answer 3

History
- MIST AMPLE if HD unstable and emergent setting, otherwise:

• PC: timing, volume, colour/nature (red vs coffee-ground),
• consequences: LOC, headache, visual changes, pre-syncrope/syncope
• DDX: alcohol history for varices, recent coughing/retching for mallory Weiss, NSAIDS/H.pylori infection for PUD. malignancy unlikely.
• PMHx, PSHx, medications, allergies
• SNAP

Question 4

Haematemesis - Examination

Answer 4

Examination
Initial as per A to E assessment
- General appearance + vitals
- Gastro examination
- Cardioresp: signs of shock

Question 5

Haematemesis - Investigations

Answer 5

Investigations

• Bedside: VBG, ECG,
• Bloods: G+H/xmatch, FBC, coags

Question 6

Haematemesis - Management

Answer 6

Management
Acute - if HD unstable
- activate MTP
- fluid resus
- Terlipressin if suspected variceal
- Metoclopromide - pro-kinetic
- disposition is urgent gastro for upper endoscopy for diagnostic and therapeutic exploration

Supportive

• keep NBM
• cease NSAIDs and other meds that worsen bleeding