Haematemesis

Question 1

What is haematemesis?

Answer 1

Vomiting of blood.

Question 2

What questions need to be asked in the history of haematemesis?

Answer 2

• Colour: is it fresh red blood ot dark brown?
• Onset: was the haematemesis preceded by intense retching or was blood staining apparent in the first vomit?
• History of dyspepsia, peptic ulceration, GI bleeding or liver disease
• Alcohol, NSAID or glucocorticoid ingestion

Question 3

How can haematemesis be differentiated between above or below the gastro-oesophageal sphincter?

Answer 3

Above gastro-oesophageal sphincter: fresh blood may be present in the mouth, as well as in the vomit

Below gastro-oesophageal sphincter: fresh blood appears on after the patient has vomited forcefully several times

Question 4

What investigations need to be ordered for haematemesis?

Answer 4

• Routine bloods:
  
  • FBC
  • U&Es
  • LFTs
  • Clotting profile
• VBG
• Oesophagogastroduodenoscopy (OGD)
• Erect CXR
• CT abdomen with IV contrast

Question 5

Briefly describe the management of haematemesis

Answer 5

Patients with haematemesis can be extremely unstable. The first step in their management is a rapid ABCDE assessment, to insert two large bore IV cannulas, start fluid resuscitation if needed, and crossmatch blood.

Most cases will warrant an upper GI endoscopy (OGD), from which a range of therapeutic options are available depending on the underlying causes suspected or confirmed.

Question 6

Briefly describe the treatment for peptic ulcer disease

Answer 6

Requires injections of adrenaline and cauterisation of the bleeding. High dose intravenous PPI therapy should be administered (e.g. IV 40mg omeprazole) to reduce acid secretion +/- H. Pylori eradication therapy if necessary.

Question 7

Briefly describe the treatment of oesophageal varices

Answer 7

Management should be swift and performed at the same time as active resuscitation, including the use of blood products and propylactic antibiotics:

• Endoscopic banding is the most definitive method of management however can be technically difficult
• Somatostatin analogues (e.g. octreotide) or vasopressors (e.g. terlipressin) should also be started, acting to reduce splanchnic blood flow and hence reduce bleeding
• Long term management warrants repeated banding of the varices and long-term beta-blocker therapy