Haematemesis Flashcards
Describe the immediate management of a patient who has lost a lot of blood.
ABCDE
What landmark defines the terms ‘upper GI’ and ‘lower GI’?
The ligament of trietz (this is towards the distal end of the duodenum)
List the differential diagnosis for haematemesis.
Oesophagitis/gastritis/duodenitis Bleeding peptic ulcer Oesophageal varices Mallory-Weiss tear Gastric cancer Oesophageal cancer Arteriovenous malformation
What is haematemesis?
vomiting blood
Describe two additional components in the management of upper GI bleeds that are caused by oesophageal varices.
Terlipressin 1-2 mg, 4-6 hourly
Prophylactic antibiotics
Describe the two scoring systems for upper GI bleeds.
Glasgow-Blatchford – stratifies patients presenting with upper GI bleeds into low and high-risk categories. It is independent of endoscopy.
Rockall – involves a more comprehensive assessment of haematemesis. It is used to predict risk of re-bleeding and mortality. Based on age, shock, comorbidities and endoscopy findings.
When is emergency endoscopy indicated?
Unstable patient with severe acute upper GI bleeding immediately after resuscitation
Suspicion of ongoing upper GI bleed and Glasgow-Blatchford > 6
Patients with a previous aortic graft to exclude aorto-enteric fistula
Other than OGD, list two other useful investigations for upper GI bleeds.
Erect CXR
Perforated peptic ulcer may cause haematemesis and pneumoperitoneum
A left-sided pleural effusion may be seen in Boerhaave’s perforation
CT Chest/Abdomen
Which investigation does all patients with aortic grafts need?
Contrast CT aortogram to rule out aorto-enteric fistula
List some questions that are important to ask patients presenting with upper GI bleeds.
How much blood was there?
What did the blood look like? (Fresh or coffee grounds)
Has there been any blood in the stool?
Did vomiting trigger the haematemesis?
Has there been any recent weight loss? (malignancy)
Have you had any problems swallowing? (oesophageal malignancy)
Have you experienced easy bruising, abdominal distension, puffy ankles or lethargy? (liver failure)
Has there been any epigastric pain?
Why is it important to ask about the character of the blood?
Fresh blood suggests upper GI bleed
Coffee grounds vomit suggests that the blood has been partially digested by stomach acids
What is the difference between melaena and haematochezia?
Melaena – caused by upper GI bleeds and digestion of the blood during GI transit
Haematochezia – fresh blood in stools
Usually caused by lower GI haemorrhage or by profuse upper GI bleed or if GI transit times are rapid
Why is it important to ask whether vomiting triggered the haematemesis?
Forceful vomiting can cause Mallory-Weiss tears and Boerhaave’s perforation, which lead to haematemesis
List some key features that you should look out for in the past medical history.
Previous upper GI haemorrhage
Heartburn or epigastric pain (may suggest peptic ulcer disease or oesophagitis/gastritis/duodenitis)
History of GORD (can lead to oesophageal cancer)
Aortic repair with grafts
Bleeding tendency
Chronic liver disease
List some key features that you should look out for in the drug history.
Anticoagulants
Drugs that increase risk of PUD (e.g. NSAIDs, aspirin, bisphosphonates, steroids)
Drugs that cause liver toxicity (e.g. methotrexate, amiodarone)
Beta-blockers (can mask signs of shock)
List some key features that you should look out for in the social history.
Excessive alcohol consumption (risk of cirrhosis and PUD)
Smoking (risk of PUD and GI malignancy)
IV drug use and tattoos (risk of viral hepatitis)
Why is it important to take note of any needle track marks and piercings on physical examination?
They are both risk factors for viral hepatitis
List some signs of liver disease on examination.
Jaundice Scratch marks Spider naevi Bruising Palmar erythema Dupuytren’s contracture Gynaecomastia Ascites Ankle oedema
What does purpura suggest?
Thrombocytopenia
List some significant signs that could be found on palpation and state what they suggest.
Splenomegaly – can be a sign of portal hypertension
Epigastric tenderness – can suggest PUD or gastritis/duodenitis
Virchow’s lymphadenopathy – suggests GI malignancy
List some significant signs that could be found on DRE and state what they suggest.
Haemorrhoids – could be a consequence of portal hypertension
Melaena or haematochezia – confirms GI bleed
List some features of liver disease in the blood results.
Macrocytic anaemia Low albumin Raised liver enzymes Raised bilirubin Raised GGT Prolonged clotting times Raised urea
List some causes of macrocytic anaemia.
B12 deficiency
Folate deficiency
Alcoholism
List some causes of low albumin.
Chronic liver failure
Malnutrition
Malabsorption
Nephrotic syndrome
What derangement of the liver function tests is consistent with alcohol abuse?
Raised GGT in the absence of raised ALP
What does raised urea in the context of normal renal function suggest?
It suggests that the patient has had a ‘protein meal’ of some form – which is most likely to be due to the digesting of red blood cells
What other investigations may be useful in patients with upper GI bleeds?
Viral hepatitis and HIV serology
Urinalysis (may show proteinuria, which, in the context of hypoalbuminaemia, would suggest nephrotic syndrome)
Describe the management of a patient awaiting endoscopy.
Regular observation NBM IV fluids Pro-kinetic drugs (e.g. erythromycin, metoclopramide) 1 hour before endoscopy Correct coagulopathy/platelets
State two important complications of alcoholism that you must bear in mind when taking care of an alcoholic patient.
Thiamine – prevents Wernicke-Korsakoff syndrome
Withdrawal – prescribe chlordiazepoxide
Other than endoscopy, list two other ways of visualising a bleed.
Angiography
Laparotomy
List three methods of stopping the bleeding from oesophageal varices.
Endoscopic band ligation Injection sclerotherapy Balloon tamponade (Sengstaken-Blakemore tube or Minnesota tube)
State and describe a surgical technique used to relieve portal hypertension.
Transjugular intrahepatic portosystemic shunt (TIPS)
NOTE: this is an intrahepatic connection between the portal vein and the hepatic vein
Describe an important complication of portacaval shunting.
It can trigger hepatic encephalopathy because toxins are bypassing the liver and entering the systemic circulation
Briefly describe the long-term management of portal hypertension.
Lifestyle: stop drinking alcohol and smoking Maintain low blood pressure Antibiotics TIPS Treat hepatic encephalopathy
What is commonly used to treat hepatic encephalopathy?
Lactulose and phosphate enemas
They decrease GI transit time and minimise GI absorption
Which type of nosebleed can present with haematemesis?
Posterior nose bleeds
