Haematemesis Flashcards
What is haematemesis?
Vomiting blood
Why does haematemesis occur?
Due to bleeding from the upper GI tract
What are emergency causes of haematemesis?
- Oesophageal varices
- Gastric ulceration
What are non-emergency causes of haematemesis?
- Mallory-Weiss tears
- Oesophagitis
- Gastritis
- Gastric malignancy
- Meckel’s diverticulum
- Vascular malformations
What are key features to ascertain from a history of haematemesis?
- Timing, frequency & volume of bleeding
- Associated symptoms
- Dyspepsia
- Dysphagia
- Odynophagia
- Past medical history
- Smoking & alcohol status
- Medication Hx
- Steroids
- NSAIDs
- Anticoagulants
- Bisphosphonates
What other symptoms may patients w/ haematemesis present with?
- Haematemesis
- Malaena
- Epigastric discomfort
- Sudden collapse
- Dysphagia
What should you assess for on examination of a patient with haematemesis?
- Epigastric tenderness
- Peritonism
- Features suggestive of a potential underlying cause
- e.g. evidence of varices or liver stigmata
What investigations may be required for a case of haematemesis?
- Routine bloods
* FBC, U&Es, LFTs, and clotting - VBG
- Group & Save
* Significant haematemesis (esp suspected variceal bleed) should have at least 4 units of blood cross-matched. - Oesophagogastroduodenoscopy (OGD)
- Definitive investigation for haematemesis
- Should be performed within 12 hours
- Erect CXR
* To visualise pneumoperitoneum w/ suspected perforated peptic ulcer. - CT abdo with IV contrast (triple phase)
* To assess any active bleeding in an unstable patient, esp if endoscopy is unremarkable or the patient is too unwell to undergo invasive investigation
What tools are used for risk assessment when a patient presents with haematemesis?
- Glasgow-Blatchford score at first assessment
- Rockall score after endoscopy
What is the name of the scoring system used to risk stratify patients admitted with an upper GI bleed, based on clinical & biochemical parameters?
Glasgow-Blatchford Bleeding Score
(can be calculated prior to OGD)
What is the Rockall Score?
Score used to identify patients at risk of adverse outcome following acute upper GI bleed
- Includes age, diagnosis, evidence of bleeding, BP, comorbidities.
What are oesophageal varices?
Dilations of the porto-systemic venous anastomoses in the oesophagus. These dilated veins are swollen & thin-walled, therefore prone to rupture, with the potential to cause a catastrophic haemorrhage
What is the most common cause for oesophageal varices?
Portal hypertension resulting from alcoholic liver disease
Any haematemesis in a patient w/ known history of alcohol abuse should be investigated with an urgent OGD.
How are oesophageal varices managed acutely?
- A-E assessment & IV access w/ fluid resusc if needed
- Blood products (e.g. FFP, Vitamin K)
* To correct clotting - Somatostatins (e.g. Ocreotide) / Vasopressins (e.g. Terlipressin)
* Reduces splanchnic blood flow, treating initial haemostasis and preventing rebleeding - Prophylactic antibiotics
* Quinolones are typically used - Endoscopic variceal band ligation (Most definitive treatment)
- Sengstaken-Blakemore tube
* If uncontrolled haemorrhage - Transjugular Intrahepatic Portosystemic Shunt (TIPSS)
* If above measures fail
How are oesophageal varices managed in the long-term?
- Repeat Endoscopic variceal band ligation
* Performed at 2 weekly intervals until all varices eradicated - Beta blocker therapy (e.g. Propanolol)
How common are gastric ulcers as a cause for haematemesis?
Gastric ulcers account for about 60% of haematemesis cases. (Most common cause)
What is a gastric ulcer?
Break in the lining of the GI tract, extending through the muscularis mucosa.
How can a gastric ulcer result in haematemesis?
Erosion into a significant vessel may produce considerable haemorrhage
What sign will typically be seen on the abdominal XR of a patient presenting with a perforated gastric ulcer?
Subdiaphragmatic free gas (Pneumoperitoneum)
Where in the stomach do ulcers typically occur?
Most commonly on the lesser curve of the stomach (20%) or posterior duodenum (40%)
What features may be present with a case of perforated gastric ulcer?
- Active ulcer disease / H. Pylori positive
- History of NSAID or steroid use
- Previous epigastric symptoms
- Suggesting peptic ulceration.
How do you manage a perforated peptic ulcer?
- Endoscopy
- Injections of adrenaline to ulcer site
- Cauterisation of bleeding
- High dose IV PPI (40mg omeprazole)
* To reduce acid secretion - H.pylori eradication therapy
PPI (e.g. Omeprazole) + 2 Antibiotics (Clarithromycin + Amoxicillin or Metronidazole) for 7 days
What is a Mallory-Weiss tear?
Episodes of severe / recurrent vomiting lead to a tear in the epithelial lining of the oesophagus, resulting in minor haematemesis.
- Most cases are benign and will resolve spontaneously
How do you manage a Mallory-Weiss tear?
Reassurance & monitoring
- Most cases are benign and will resolve spontaneously
However, prolonged or worsening haematemesis warrants investigation with an OGD.
What is Oesophagitis? & What is it caused by?
Inflammation of the intraluminal epithelial layer of the oesophagus.
Most common cause = Gastric acid reflux (GORD)
Less common causes include:
- Infections (typically Candida Albicans)
- Medication (e.g. bisphosphonates)
- Radiotherapy
- Ingestions of toxic substances
- Crohn’s disease
What is the management of haematemesis?
- Rapid ABCDE assessment
- Insert 2 wide bore cannula & start IV fluid resuscitations
- Group and save
* for transfusion if massive bleeding occurs - Treat underlying cause of bleeding
