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General Surgery > Haematemesis > Flashcards

Haematemesis Flashcards

1
Q

What is haematemesis?

A

Vomiting blood

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2
Q

Why does haematemesis occur?

A

Due to bleeding from the upper GI tract

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3
Q

What are emergency causes of haematemesis?

A
  • Oesophageal varices
  • Gastric ulceration
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4
Q

What are non-emergency causes of haematemesis?

A
  • Mallory-Weiss tears
  • Oesophagitis
  • Gastritis
  • Gastric malignancy
  • Meckel’s diverticulum
  • Vascular malformations
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5
Q

What are key features to ascertain from a history of haematemesis?

A
  • Timing, frequency & volume of bleeding
  • Associated symptoms
    • Dyspepsia
    • Dysphagia
    • Odynophagia
  • Past medical history
  • Smoking & alcohol status
  • Medication Hx
    • Steroids
    • NSAIDs
    • Anticoagulants
    • Bisphosphonates
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6
Q

What other symptoms may patients w/ haematemesis present with?

A
  • Haematemesis
  • Malaena
  • Epigastric discomfort
  • Sudden collapse
  • Dysphagia
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7
Q

What should you assess for on examination of a patient with haematemesis?

A
  • Epigastric tenderness
  • Peritonism
  • Features suggestive of a potential underlying cause
    • e.g. evidence of varices or liver stigmata
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8
Q

What investigations may be required for a case of haematemesis?

A
  1. Routine bloods
    * FBC, U&Es, LFTs, and clotting
  2. VBG
  3. Group & Save
    * Significant haematemesis (esp suspected variceal bleed) should have at least 4 units of blood cross-matched.
  4. Oesophagogastroduodenoscopy (OGD)
  • Definitive investigation for haematemesis
  • Should be performed within 12 hours
  1. Erect CXR
    * To visualise pneumoperitoneum w/ suspected perforated peptic ulcer.
  2. 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
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9
Q

What tools are used for risk assessment when a patient presents with haematemesis?

A
  • Glasgow-Blatchford score at first assessment
  • Rockall score after endoscopy
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10
Q

What is the name of the scoring system used to risk stratify patients admitted with an upper GI bleed, based on clinical & biochemical parameters?

A

Glasgow-Blatchford Bleeding Score

(can be calculated prior to OGD)

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11
Q

What is the Rockall Score?

A

Score used to identify patients at risk of adverse outcome following acute upper GI bleed

  • Includes age, diagnosis, evidence of bleeding, BP, comorbidities.
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12
Q

What are oesophageal varices?

A

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

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13
Q

What is the most common cause for oesophageal varices?

A

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.

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14
Q

How are oesophageal varices managed acutely?

A
  1. A-E assessment & IV access w/ fluid resusc if needed
  2. Blood products (e.g. FFP, Vitamin K)
    * To correct clotting
  3. Somatostatins (e.g. Ocreotide) / Vasopressins (e.g. Terlipressin)
    * Reduces splanchnic blood flow, treating initial haemostasis and preventing rebleeding
  4. Prophylactic antibiotics
    * Quinolones are typically used
  5. Endoscopic variceal band ligation (Most definitive treatment)
  6. Sengstaken-Blakemore tube
    * If uncontrolled haemorrhage
  7. Transjugular Intrahepatic Portosystemic Shunt (TIPSS)
    * If above measures fail
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15
Q

How are oesophageal varices managed in the long-term?

A
  1. Repeat Endoscopic variceal band ligation
    * Performed at 2 weekly intervals until all varices eradicated
  2. Beta blocker therapy (e.g. Propanolol)
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16
Q

How common are gastric ulcers as a cause for haematemesis?

A

Gastric ulcers account for about 60% of haematemesis cases. (Most common cause)

17
Q

What is a gastric ulcer?

A

Break in the lining of the GI tract, extending through the muscularis mucosa.

18
Q

How can a gastric ulcer result in haematemesis?

A

Erosion into a significant vessel may produce considerable haemorrhage

19
Q

What sign will typically be seen on the abdominal XR of a patient presenting with a perforated gastric ulcer?

A

Subdiaphragmatic free gas (Pneumoperitoneum)

20
Q

Where in the stomach do ulcers typically occur?

A

Most commonly on the lesser curve of the stomach (20%) or posterior duodenum (40%)

21
Q

What features may be present with a case of perforated gastric ulcer?

A
  • Active ulcer disease / H. Pylori positive
  • History of NSAID or steroid use
  • Previous epigastric symptoms
    • Suggesting peptic ulceration.
22
Q

How do you manage a perforated peptic ulcer?

A
  1. Endoscopy
  • Injections of adrenaline to ulcer site
  • Cauterisation of bleeding
  1. High dose IV PPI (40mg omeprazole)
    * To reduce acid secretion
  2. H.pylori eradication therapy

PPI (e.g. Omeprazole) + 2 Antibiotics (Clarithromycin + Amoxicillin or Metronidazole) for 7 days

23
Q

What is a Mallory-Weiss tear?

A

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
24
Q

How do you manage a Mallory-Weiss tear?

A

Reassurance & monitoring

  • Most cases are benign and will resolve spontaneously

However, prolonged or worsening haematemesis warrants investigation with an OGD.

25
Q

What is Oesophagitis? & What is it caused by?

A

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
26
Q

What is the management of haematemesis?

A
  1. Rapid ABCDE assessment
  2. Insert 2 wide bore cannula & start IV fluid resuscitations
  3. Group and save
    * for transfusion if massive bleeding occurs
  4. Treat underlying cause of bleeding

General Surgery (12 decks)

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