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Yr 3 Oxford Clinical Cases > Haematemesis > Flashcards

Haematemesis Flashcards

1
Q

Describe the immediate management of a patient who has lost a lot of blood.

A

ABCDE

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2
Q

What landmark defines the terms ‘upper GI’ and ‘lower GI’?

A

The ligament of trietz (this is towards the distal end of the duodenum)

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3
Q

List the differential diagnosis for haematemesis.

A 
Oesophagitis/gastritis/duodenitis
Bleeding peptic ulcer 
Oesophageal varices 
Mallory-Weiss tear 
Gastric cancer
Oesophageal cancer 
Arteriovenous malformation
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4
Q

What is haematemesis?

A

vomiting blood

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5
Q

Describe two additional components in the management of upper GI bleeds that are caused by oesophageal varices.

A

Terlipressin 1-2 mg, 4-6 hourly

Prophylactic antibiotics

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6
Q

Describe the two scoring systems for upper GI bleeds.

A

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.

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7
Q

When is emergency endoscopy indicated?

A

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

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8
Q

Other than OGD, list two other useful investigations for upper GI bleeds and what might you see on them?

A

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

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9
Q

Which investigation does all patients with aortic grafts need?

A

Contrast CT aortogram to rule out aorto-enteric fistula

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10
Q

List some questions that are important to ask patients presenting with upper GI bleeds.

A

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?

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11
Q

Why is it important to ask about the character of the blood?

A

Fresh blood suggests upper GI bleed

Coffee grounds vomit suggests that the blood has been partially digested by stomach acids

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12
Q

What is the difference between melaena and haematochezia?

A

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

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13
Q

Why is it important to ask whether vomiting triggered the haematemesis?

A

Forceful vomiting can cause Mallory-Weiss tears and Boerhaave’s perforation, which lead to haematemesis

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14
Q

List some key features that you should look out for in the past medical history.

A

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

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15
Q

List some key features that you should look out for in the drug history.

A

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)

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16
Q

List some key features that you should look out for in the social history.

A

Excessive alcohol consumption (risk of cirrhosis and PUD)
Smoking (risk of PUD and GI malignancy)
IV drug use and tattoos (risk of viral hepatitis)

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17
Q

Why is it important to take note of any needle track marks and piercings on physical examination?

A

They are both risk factors for viral hepatitis

18
Q

List some signs of liver disease on examination.

A 
Jaundice 
Scratch marks 
Spider naevi
Bruising 
Palmar erythema
Dupuytren’s contracture 
Gynaecomastia 
Ascites 
Ankle oedema
19
Q

What does purpura suggest?

A

Thrombocytopenia (from ITP, Chronic liver disease)

20
Q

List some significant signs that could be found on palpation and state what they suggest.

A

Hepatomegaly- Liver disease (early stage)
Splenomegaly – can be a sign of portal hypertension
Epigastric tenderness – can suggest PUD or gastritis/duodenitis
Virchow’s lymphadenopathy – suggests GI malignancy

21
Q

List some significant signs that could be found on DRE and state what they suggest.

A

Haemorrhoids – could be a consequence of portal hypertension
Melaena or haematochezia – confirms GI bleed

22
Q

List some features of liver disease in the blood results.

A 
Macrocytic anaemia - B12 and folate deficient if alcoholic
Low albumin- liver/ malnutrition
Raised liver enzymes 
Raised bilirubin 
Raised GGT 
Prolonged clotting times 
Raised urea
23
Q

List some causes of macrocytic anaemia.

A

B12 deficiency
Folate deficiency
-Alcoholism

24
Q

List some causes of low albumin.

A

Chronic liver failure
Malnutrition
Malabsorption
Nephrotic syndrome

25
Q

What derangement of the liver function tests is consistent with alcohol abuse?

A

Raised GGT in the absence of raised ALP

26
Q

What does raised urea in the context of normal renal function suggest?

A

Pre-renal uraemia
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

27
Q

What other investigations may be useful in patients with upper GI bleeds?

A

Viral hepatitis and HIV serology

Urinalysis (may show proteinuria, which, in the context of hypoalbuminaemia, would suggest nephrotic syndrome)

28
Q

Describe the management of a patient awaiting endoscopy.

A 
Regular observation 
NBM
IV fluids 
Pro-kinetic drugs (e.g. erythromycin, metoclopramide) 1 hour before endoscopy 
Correct coagulopathy/platelets
29
Q

State two important complications of alcoholism that you must bear in mind when taking care of an alcoholic patient (+ 2 drugs you’d administer for this)

A

Thiamine – prevents Wernicke-Korsakoff syndrome

Withdrawal – prescribe chlordiazepoxide

30
Q

Other than endoscopy, list two other ways of visualising a bleed.

A

Angiography

Laparotomy- esp posterior perforated peptic ulcerer

31
Q

List three methods of stopping the bleeding from oesophageal varices.

A 
Endoscopic band ligation 
Injection sclerotherapy 
Balloon tamponade (Sengstaken-Blakemore tube or Minnesota tube)
32
Q

State and describe a surgical technique used to relieve portal hypertension.

A

Transjugular intrahepatic portosystemic shunt (TIPS)

NOTE: this is an intrahepatic connection between the portal vein and the hepatic vein

33
Q

Describe an important complication of portacaval shunting.

A

It can trigger hepatic encephalopathy because toxins are bypassing the liver and entering the systemic circulation

34
Q

Briefly describe the long-term management of portal hypertension.

A

Lifestyle: stop drinking alcohol and smoking
Maintain low blood pressure - propanalol/ isobride
Antibiotics - ciproflaxin (50% develop sepsis)
TIPS
Treat hepatic encephalopathy (low protein diet, lactulose/enemas)

35
Q

What is commonly used to treat hepatic encephalopathy?

A

Low protein diet
Lactulose and phosphate enemas
They decrease GI transit time and minimise GI absorption

36
Q

Which type of nosebleed can present with haematemesis?

A

Posterior nose bleeds from sphenopalatine artery

37
Q

Why is the balloon tamponade note first line? When is it’s use indicated?

A
  • rebleed rate of 50%
  • serious complications associated (oesophageal ulcers + aspiration pneumonia)
  • Used when ligation has failed/ not possible because too much blood obstructing the view
38
Q

Why might you get clotted blood in vomit + Melaena?

A

Blood has been digested by stomach
Indicative of Upper GI bleed
+ heartburn is indicative of bleeding peptic ulcer

39
Q

Describe the management of a bleeding peptic ulcer

A
  1. Bleeding stopped via endoscopic fibrin sealant + adrenaline injection around ulcer
  2. Biopsy (to check if H. Pylori +ve)
  3. Omeprazole infusion (to reduce rebleed risk)
  4. Triple therapy: Clarithromycin + amoxicillin + PPI
40
Q

Continuous vomitting prior to haemetemesis? Differentials?

A

Mallory-Weiss tear (tear in oesophageal mucosa)

Boerhaave’s perforation

41
Q

3 reasons why alcoholics are prone to haematemesis?

A
  1. Physiology: Liver disease–> decreased clotting factor synthesis= bleeding risk. PUD, gastritis risk
  2. Anatomy: Portal hypertension + oesophageal varices
  3. Behavioural: Vomit often –> Mallory-weiss tear, Boerhaave’s perforation and rupture of oesophageal varix

Yr 3 Oxford Clinical Cases (28 decks)

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