Haematemesis Flashcards
Describe the immediate management of a patient who has lost a lot of blood.
ABCDE
What landmark defines the terms ‘upper GI’ and ‘lower GI’?
The ligament of trietz (this is towards the distal end of the duodenum)
List the differential diagnosis for haematemesis.
Oesophagitis/gastritis/duodenitis Bleeding peptic ulcer Oesophageal varices Mallory-Weiss tear Gastric cancer Oesophageal cancer Arteriovenous malformation
What is haematemesis?
vomiting blood
Describe two additional components in the management of upper GI bleeds that are caused by oesophageal varices.
Terlipressin 1-2 mg, 4-6 hourly
Prophylactic antibiotics
Describe the two scoring systems for upper GI bleeds.
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.
When is emergency endoscopy indicated?
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
Other than OGD, list two other useful investigations for upper GI bleeds.
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
Which investigation does all patients with aortic grafts need?
Contrast CT aortogram to rule out aorto-enteric fistula
List some questions that are important to ask patients presenting with upper GI bleeds.
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?
Why is it important to ask about the character of the blood?
Fresh blood suggests upper GI bleed
Coffee grounds vomit suggests that the blood has been partially digested by stomach acids
What is the difference between melaena and haematochezia?
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
Why is it important to ask whether vomiting triggered the haematemesis?
Forceful vomiting can cause Mallory-Weiss tears and Boerhaave’s perforation, which lead to haematemesis
List some key features that you should look out for in the past medical history.
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
List some key features that you should look out for in the drug history.
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)