Haematemesis

Question 1

What counts as shock

Answer 1

BP<90/60

Question 2

Haematemesis can occur due to a bleed proximal to which structure

Answer 2

Proximal to the ligament of Treitz (demarcates boundary between duodenum and jejenum)

Question 3

What is the rockall score and what is it used for

Answer 3

The Rockall score 1 was developed to predict the risk of rebleeding and mortality in patients with upper GI haemorrhage, but is often used as an indicator for severity that helps guide urgency of endoscopy.

Initially, considers clinical findings alone (age, shock and comorbidities). The final Rockall score is a combination of pre- and post- endoscopy findings.
It includes stigmata of recent haemorrhage and diagnosis.

Question 4

What can haematochezia signify

Answer 4

Haematochezia is fresh blood in the stools. It is usually due to lower GI haemorrhage but can be due to an upper GI haemorrhage if the bleeding is profuse or the GI transit time fast (note that blood can act as a cathartic, reducing transit time).

Question 5

What has liver failure to do with haematemesis

Answer 5

Could be varices or also bleeding tendency

Question 6

Drugs causing liver toxicity

Answer 6

methotrexate, a - methyldopa, amiodarone

Question 7

Raised GGT, without any change to ALP?

Answer 7

Suggestive of alcohol abuse

Question 8

According to the final Rockall score, which diagnoses are least and most likely to bleed again

Answer 8

0 points- Mallory-weiss tear
1 point- all other diagnoses
2 points-malignancy of upper GI tract

Question 9

Mortality associated with haematemesis

Answer 9

10%

Question 10

Indications for emergency endoscopy in patient with haematemesis

Answer 10

1. Suspicion of continuing upper GI bleed
2. Suspicion of eosophageal varices as cause of GI bleed
3. An initial Rockall score of >3 (if >6 surgery probably indicated)
4. If patient has aortic graft- in which case you should suspect aorto-enteric fistula until proven otherwise

Question 11

Boerghaave’s perforation might have what effect in the thorax

Answer 11

You might see a left-sided pleural effusion

Question 12

What are you suspecting if forceful vomiting triggered the haematemesis

Answer 12

Malllory weiss tear/boerhaave’s perforation

Question 13

Epigastric pain worse on touching toes

Answer 13

Suggests GORD

Question 14

How might b-blocker affect haematemesis

Answer 14

It might mask the signs of shock by preventing a tachycardia in patient who is hypovolaemic

Question 15

Which drug is used to reduce portal hypertension and what is its mechanism of action

Answer 15

Glypressin=ADH agonist that reduces mesenteric blood flow and thus reduces portal pressure. An IV infusion effective in 80% patient

Question 16

What do you give to somebody with haematemesis and suspected chornic liver disease and why

Answer 16

Glyspressin and Abx cover (50% of of patients with liver disease and upper GI bleeding develop sepsis)

Question 17

What drug do you want to give for alcohol withdrawal

Answer 17

Chlordiaepoxide

Question 18

What might be an indication for laparotomy to find the source of a GI bleed

Answer 18

In particular, posterior peptic ulcers- necessary to proceed to laparotomy to visualise and stop bleeding

Question 19

Procedures to stop bleeding with eosophageal varices

Answer 19

Endoscopic band ligation (THEN, if still bleeding)…
Sclerotherapy
(THEN, if still bleeding)…
Balloon tamponade (but associated with eosophageal ulceration and aspiration pneumonia…
(THEN, if still bleeding)…
TIPS
(THEN, if still bleeding)…
Portocaval portosystemic shunt (surgical)

Question 20

Why are portocaval shunts now rarely performed

Answer 20

Remember that a major role of the liver is to metabolize many substances absorbed by the gut into the portal circulation (‘first-pass metabolism’) so that the blood is ‘detoxified’ before entering the systemic circulation. By placing a shunt that bypasses the liver, many toxins absorbed by the gut will enter the systemic circulation and can trigger an encephalopathy. Because of this, portocaval shunts are now rarely performed.

Question 21

Long term management for portal HTN?

Answer 21

Lifestyle advice; keep BP low (propanolol or isosorbide mononitrate typically used); Abx (as 50% of patients with liver cirrhosis and upper GI bleeding will develop sepsis; TIPS/TIPSS; treat encephalopathy (see below)

Question 22

How do we treat encephalopathy if we have performed portosystemic shunting

Answer 22

Liver usually removes lots of dietary toxins from blood before they reach systemic circulation.

If this filtering does not occur due to liver failure or portosystemic shunts, the patient is at risk of encephalopathy.

If they do,
Place on very low protein diet and give lactulose or enamas to decrease GI transit time and minimise GI absorption

Lactulose also reduces pH in faces making the environment more hostile to ammonia producing bacteria