Haematemesis Flashcards
If someone is in shock, you need to do fluid resuscitation. What does this consist of?
- High flow oxygen (15L/min)
- Send bloods for: VBG (which will show lactate and estimates Hb), clotting, cross match 4 units blood, urea and creatinine (is urea high enough to suggest GI bleed?), electrolytes, liver enzymes/bilirubin/albumin (suggest CLD - causes oesophageal varices and haematemesis)
- Volume resuscitation: unto 2L of warmed crystalloid solution (e.g. Hartmanns), 1/2 units blood
- Monitoring - ?urinary catheter
What is haematemesis and what are the potential causes of it?
Haematemesis = bleeding in upper GI tract
Causes = oesophagitis/gastritis/duodenitis, bleeding peptic ulcer, oesophageal varices, Mallory-Weiss tear, oesophageal cancer
If varices are suspected, what should you give in the initial management
- Terlipressin 1-2mg 4-6 hourly. Terlipressin = ADH agonist, causes splanchnic vasoconstriction so reduces mesenteric blood flow and portal pressure.
- Prophylactic antibiotics
What are the indications for an emergency endoscopy in a patient with haematemesis? What other investigations should be ordered?
Indications = continuing upper GI bleed and Blatchford score of 6 or above. Also if pt has aortic graft they should have emergency endoscopy to ensure that it isn’t an aorta-enteric fistula.
Investigations:
CXR - check for haematemesis and pneumoperitoneum.
CT scan of chest/abdo - aortic graft pts, to rule out aorto-enteric fistula.
What information in the PC must you gather
- How much blood has pt vomited
- Character of vomit - fresh blood = upper GI. Coffee ground = partially digested. Faeculent vomit = small bowel obstruction
- Melaena or frank blood in stools? - melaena = upper GI haemorrhage. Fresh blood in stools = often lower GI but can also be upper GI haemorrhage if profuse bleeding
- Forceful vomit trigger haematemesis? - suspect Mallory Weiss tear
- Recent weight loss - ?upper GI malignancy
- Problems swallowing - ?oesophageal malignancy
- Easy bruising/distended abdomen/puffy ankles/lethargy - liver failure.
- Epigastric pain - gastric carcinoma or GORD
What information from the PMH is important
Heartburn/epigastric pain = suspect bleeding peptic ulcer or bleeding oesophagitis/gastritis/duodenitis
GORD history = chronic GORD can cause oesophagitis and Barrett’s oesophagus leading to adenocarcinoma
Aortic graft repair = aorto-enteric fistula
Bleeding tendency = clotting problem
CLD = bleeding tendency + oesophageal varices
What aspects of the drug hx are important
- Anticoagulants - clotting problem?
- NSAIDS/bisphosphonates/clopidogrel -suspect peptic ulcer disease
- Methotrexate/amiodarone = causes long term liver toxicity
- B-blocker = may mask signs of shock by preventing tachycardia in hypovolaemic patient
What aspects of the social hx are important
- Excess EtOH consumption = increased risk of cirrhosis leading to oesophageal varices/gastritis/peptic ulcer disease
- Smoking - increases risk of upper GI malignancy and peptic ulcer disease
- IV drug use / tattoos - ?chronic viral hepatitis
What signs would indicate liver disease and cirrhosis
Jaundice, scratch marks, bruising, spider naevi (>4), palmar erythema, Dupuytrens contracture, gynaecomastia, ascites, ankle oedema, caput medusae
What would purpura indicate
Thrombocytopenia
What does splenomegaly suggest and give a cause
Portal hypertension - could be due to liver cirrhosis
Epigastric tenderness indicates what cause of haematemesis
Gastritis/duodenitis
Finding haemorrhoids on a DRE indicates what?
Portal hypertension
Excess alcohol consumption causes what kind of anaemia
Macrocytic (+B12/folate)
What could be causes of low albumin
CLD, malnutrition, malabsorption or renal nephrotic syndrome
Raised liver enzymes ALT and AST indicate what
Hepatocyte damage consistent with alcohol abuse and liver cirrhosis
Raised GGT in the absence of a raised ALP indicates
Alcohol abuse
How should patients with haematemesis be managed
- Regular obs
- Nil by mouth - until endoscopy done
- Fluids
- Pro-kinetic (e.g. metoclopramide) to empty stomach
- Correct coagulopathy and/or platelets
If alcohol abuse, also consider thiamine and monitor for alcohol withdrawal symptoms
How can bleeding be stopped endoscopically
- Endoscopic band ligation (preferred)
- Endoscopic sclerotherapy
- Balloon tamponade
- Transjugular intrahepatic portosystemic shunt (TIPS/TIPSS) - create shunt between hepatic vein to portal vein to relieve portal hypertension.
- Portocaval shunt - shunt between portal and systemic circulation; bypassing liver and reduces portal hypertension (which contributes to oesophageal varices). However portocaval shunts can cause encephalopathy (as liver bypassed).
What steps are involved in the management of portal hypertension
- Lifestyle
- BP low - minimises risk of rebleeding of oesophageal varices. May be prescribed propranolol or isosorbide mononitrate
- Abx - one week course
- TIPS/TIPSS
- Treat encephalopathy e.g. via enema or lactulose
In someone who takes ibuprofen, what is the most likely diagnosis for cause of upper GI bleed
Bleeding peptic ulcer
If someone has a H pylori infection what is given as treatment
Omeprazole (PPI) and 2 abx
If someone presents with chest pain after vomiting (1/more episodes) what should you suspect?
Mallory-Weiss tear or more serious Boerhaaves perforation.
Need to do OGD
Why might nosebleed (epistaxis) cause vomiting?
If blood falls back into pharynx
