Haematemesis

Question 1

Sequence of events

Answer 1

Open question- tell me about what has been going on
Timeline- when did it start and how has it progressed?
Timing- has it happened before? Does it come and go?

Question 2

Symptom analysis

Answer 2

Site- is it definitely in vomit, not from coughing or a nosebleed? Red blood or coffee ground colour?
Amount- streaks, a teaspoon, or more
Trigger- anything trigger it? We’re you wrenching before bringing it up?

Question 3

Oesophageal varices

Answer 3

History of liver disease/ alcoholism
Bleeding can be extensive
Encephalopathy or alcohol withdrawal

Question 4

Mallory Weiss tear

Answer 4

Multiple vomits before haematemesis (uncontrollable wrenching or vomiting)
Commonly after binge drinking

Question 5

PUD/ gastritis/ oesophagitis

Answer 5

Previous gastritis Sx

Risk factors eg. NSAIDS, alcohol, spicy food, steroids, SSRI, bisphosphahates

Question 6

Systems review

Answer 6

FWARJNL Tiredness (anaemia)

GI- GORD, abdominal pain, change in bowel habit, blood or dark stools, any difficulties swallowing
Hepatic- yellow skin or eyes, itchy skin, swollen abdomen

Question 6

Patients perspective

Answer 6

Feelings and effect on life

Ideas concerns expectations

Question 7

PMH

Answer 7

Liver disease, peptic ulcers, previous malignancy, surgery

Question 8

DH

Answer 8

OTC, NSAID, anti platelets, anti coagulants, steroids

Question 9

FH

Answer 9

Malignancy, blending disorders

Question 10

SH

Answer 10

Smoke, alcohol, recreational drugs (inject)
Work
Home

Question 11

Oesophagitis

Answer 11

History of GORD

Fresh blood with no red flag Sx

Question 12

Upper GI malignancy

Answer 12

Alarm Sx- anaemia, weight loss, poor appetite, malaena, swallowing difficulties
Early satiety- gastric carcinoma

Question 13

Iatrogenic

Answer 13

Recent oesophageal or gastric surgery or endoscopy

Question 14

Arteriovenous malformations

Answer 14

Acute extensive haemorrhage, assoc. with HHT

Question 15

Borhaave’s syndrome

Answer 15

Oesophageal rupture due to excessive vomiting or wrenching

Severe retrosternal and abdominal pain following vomiting, alcholoism present in 40% patients

Question 16

Aorto-enteric fistula

Answer 16

Very rare

If patient is known to have an AAA or aortic graft in situ- give credence

Question 17

Investigations

Answer 17

NB- differentiate whether an acute event or a harmless chronic thing

Check observations perform abdo and PR exams
FBC UE LFT clotting CRP bone profile and perhaps group and save
Erect CXR (free air under diaphragm- perforation)
Upper GIT endoscopy
CT abdo chest- if patient has aortic graft
Perhaps angiography