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Year 3 - Medicine and Surgery book > Haematemesis > Flashcards

Haematemesis Flashcards

1
Q

If someone is in shock, you need to do fluid resuscitation. What does this consist of?

A
  1. High flow oxygen (15L/min)
  2. 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)
  3. Volume resuscitation: unto 2L of warmed crystalloid solution (e.g. Hartmanns), 1/2 units blood
  4. Monitoring - ?urinary catheter
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2
Q

What is haematemesis and what are the potential causes of it?

A

Haematemesis = bleeding in upper GI tract

Causes = oesophagitis/gastritis/duodenitis, bleeding peptic ulcer, oesophageal varices, Mallory-Weiss tear, oesophageal cancer

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3
Q

If varices are suspected, what should you give in the initial management

A
  1. Terlipressin 1-2mg 4-6 hourly. Terlipressin = ADH agonist, causes splanchnic vasoconstriction so reduces mesenteric blood flow and portal pressure.
  2. Prophylactic antibiotics
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4
Q

What are the indications for an emergency endoscopy in a patient with haematemesis? What other investigations should be ordered?

A

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.

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5
Q

What information in the PC must you gather

A
  1. How much blood has pt vomited
  2. Character of vomit - fresh blood = upper GI. Coffee ground = partially digested. Faeculent vomit = small bowel obstruction
  3. 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
  4. Forceful vomit trigger haematemesis? - suspect Mallory Weiss tear
  5. Recent weight loss - ?upper GI malignancy
  6. Problems swallowing - ?oesophageal malignancy
  7. Easy bruising/distended abdomen/puffy ankles/lethargy - liver failure.
  8. Epigastric pain - gastric carcinoma or GORD
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6
Q

What information from the PMH is important

A

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

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7
Q

What aspects of the drug hx are important

A
  1. Anticoagulants - clotting problem?
  2. NSAIDS/bisphosphonates/clopidogrel -suspect peptic ulcer disease
  3. Methotrexate/amiodarone = causes long term liver toxicity
  4. B-blocker = may mask signs of shock by preventing tachycardia in hypovolaemic patient
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8
Q

What aspects of the social hx are important

A
  1. Excess EtOH consumption = increased risk of cirrhosis leading to oesophageal varices/gastritis/peptic ulcer disease
  2. Smoking - increases risk of upper GI malignancy and peptic ulcer disease
  3. IV drug use / tattoos - ?chronic viral hepatitis
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9
Q

What signs would indicate liver disease and cirrhosis

A

Jaundice, scratch marks, bruising, spider naevi (>4), palmar erythema, Dupuytrens contracture, gynaecomastia, ascites, ankle oedema, caput medusae

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10
Q

What would purpura indicate

A

Thrombocytopenia

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11
Q

What does splenomegaly suggest and give a cause

A

Portal hypertension - could be due to liver cirrhosis

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12
Q

Epigastric tenderness indicates what cause of haematemesis

A

Gastritis/duodenitis

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13
Q

Finding haemorrhoids on a DRE indicates what?

A

Portal hypertension

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14
Q

Excess alcohol consumption causes what kind of anaemia

A

Macrocytic (+B12/folate)

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15
Q

What could be causes of low albumin

A

CLD, malnutrition, malabsorption or renal nephrotic syndrome

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16
Q

Raised liver enzymes ALT and AST indicate what

A

Hepatocyte damage consistent with alcohol abuse and liver cirrhosis

17
Q

Raised GGT in the absence of a raised ALP indicates

A

Alcohol abuse

18
Q

How should patients with haematemesis be managed

A
  1. Regular obs
  2. Nil by mouth - until endoscopy done
  3. Fluids
  4. Pro-kinetic (e.g. metoclopramide) to empty stomach
  5. Correct coagulopathy and/or platelets

If alcohol abuse, also consider thiamine and monitor for alcohol withdrawal symptoms

19
Q

How can bleeding be stopped endoscopically

A
  1. Endoscopic band ligation (preferred)
  2. Endoscopic sclerotherapy
  3. Balloon tamponade
  4. Transjugular intrahepatic portosystemic shunt (TIPS/TIPSS) - create shunt between hepatic vein to portal vein to relieve portal hypertension.
  5. 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).
20
Q

What steps are involved in the management of portal hypertension

A
  1. Lifestyle
  2. BP low - minimises risk of rebleeding of oesophageal varices. May be prescribed propranolol or isosorbide mononitrate
  3. Abx - one week course
  4. TIPS/TIPSS
  5. Treat encephalopathy e.g. via enema or lactulose
21
Q

In someone who takes ibuprofen, what is the most likely diagnosis for cause of upper GI bleed

A

Bleeding peptic ulcer

22
Q

If someone has a H pylori infection what is given as treatment

A

Omeprazole (PPI) and 2 abx

23
Q

If someone presents with chest pain after vomiting (1/more episodes) what should you suspect?

A

Mallory-Weiss tear or more serious Boerhaaves perforation.

Need to do OGD

24
Q

Why might nosebleed (epistaxis) cause vomiting?

A

If blood falls back into pharynx

25
Q

What is the Child-Pugh score used for?

A

Liver cirrhosis

26
Q

What measures the intrinsic pathway time?

What might affect the intrinsic pathway time

A

APTT (34 seconds) = intrinsic

APTT affected by heparin, haemophiliacs, von Willebrand disease

27
Q

What measures the extrinsic pathway time?

What might affect the extrinsic pathway time

A

PT (14 seconds) = extrinsic

PT affected by warfarin and liver disease

Year 3 - Medicine and Surgery book (29 decks)

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