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Y3 Oxford Cases > Haematemesis > Flashcards

Haematemesis Flashcards

1
Q

What is the conservative and initial management for a patient who has come in to ED with haematemesis and intoxication

A

ABCDE approach
Airway - is it patent, is there gurgling or stridor, does it require suction
B - respiratory distress?
C - pulse? shock?
D - GCS?
E - check for trauma or sites of blood loss

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2
Q

What is the medical management for a patient who has come in to ED with haematemesis and intoxication. HR is 130, RR 30, BP 86/52, sats 97. Old bruising.

A

Fluid resuscitation

  1. Apply High flow oxygen (15L/min)
  2. IV access
  3. Send bloods
  4. Give up to 2L of warmed crystalloid solution and consider 1 or 2 units of blood (only if fresh blood on DR)
  5. Monitor, consider catheter, CVP and arterial line
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3
Q

What bloods would you initially take from a patient with haematemesis and intoxication

A 
VBG 
Clotting
Cross-match blood
FBC
U&Es + creatinine
LFTs
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4
Q 
What is the purpose of doing the following bloods for haematemesis:
VBG 
Clotting
Cross-match blood
FBC
U&Es + creatinine
LFTs
A

VBG - rapid estimate of Hb + lactate (indicative of shock if raised) + low pH
Clotting - check for bleeding tendency that may need correcting
Cross-match blood - potential transfusion
FBC - more accurate Hb and platelet count - bleeding tendency
U&Es + creatinine - hypovolaemia or in renal failure? Raised urea (GI bleed that was broken down?), electrolyte disturbances?
LFTs - CLD, which would cause oesophageal varices

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5
Q

What are the causes of Haematemesis

A 
Oesophagitis /gastritis/duodenitis 
Bleeding peptic Ulcer
Oesophageal varices 
Mallory-Weiss tear
Oesophageal or gastric cancer 
Ateriovenous malformations 
Bleeding diathesis 
Trauma
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6
Q

What should be included in initial management for suspected varices (pre-endoscopy)

A

Terlipressin - reduces mesenteric blood flow due to vasoconstriction and portal pressure (ADH agonist)
Prophylactic antibiotics

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7
Q

What is the Blatchford score

A

Stratifies patients presenting to hospital with haematemesis into high and low risk groups
Guides which can be managed as outpatients or urgent intervention (>6)
Based on urea, Hb, systolic BP, melaena, HR, syncope, cardiac or hepatic disease

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8
Q

What is the Rockall score

A

Predicts the risk of rebleeding and mortality in patients with upper GI haemorrhage
Often used to guide urgency of endoscopy
Requires both pre and post endoscopy findings

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9
Q

What are the indications for emergency endoscopy in a patient with haematemesis.

A

Unstable patients with severe acute upper GI bleeding immediately after resus
Suspicion of continued bleeding Blatchford score of >6
Note those with an aortic graft

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10
Q

What other investigations should be requested for haematemesis

A

Oesophagogastroduodenoscopy (OGD)
Erect CXR to check for pneumoperitoneum (due to peptic ulcer)
CT chest abdomen - rule out aorto-enteric fistula for those with aortic graft

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11
Q

What questions should be asked about haematamesis when trying to establish cause i.e. oesophageal varices (HPC)

A 
How much blood was vomited?
What did it look like?
Melaena or frank blood in stool?
Forceful vomiting?
Recent weight loss?
problems swallowing? 
Easy bruising, distended abdomen, puffy ankles, lethargy?
Epigastric pain?
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12
Q

What does the character of the vomit and whether there was melaena tell you

A

Fresh blood - upper GI bleed
Coffee grounds - blood was partially digested by stomach acids (may be confused with faeculent vomiting)

Melaena due to upper GI haemorrhage
Haematochezia due to lower GI haemorrhage, but also upper if the bleeding is profuse or GI transit time is fast

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13
Q

What does forceful vomiting, recent weight loss, problems swallowing, and epigastric pain suggest with haematemesis

A

forceful - mallory-weiss tear of Boerhaave’s perforation
weight loss - upper GI malignancy
Swallowing - oseophageal malignancy
pain - gastric carcinoma (gnawing) , dyspepsia (GORD)

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14
Q

What is easy bruising, distended abdomen, puffy ankles and lethargy signs of

A

Liver failure
Explains bleeding tendency
If live is cirrhotic, may explain oesophageal varices

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15
Q

What questions about PMH should be asked about haematamesis when trying to establish cause i.e. oesophageal varices (HPC)

A 
Previous upper GI haemorrhage 
Heartburn or epigastric pain
History of GORD
Aortic repair with grafts
Bleeding tendency 
Chronic Liver disease
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16
Q

What questions about drug history should be asked about haematamesis when trying to establish cause i.e. oesophageal varices (HPC)

A

Anticoagulants
Regular NSAIDs, aspirin, clopidogrel, steroids, bisphosphonates (peptic ulceration)
Hepatotoxic drugs e.g. methotrexate, amiodarone
Beta blockers that may mask signs of shock

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17
Q

What questions about social history should be asked about haematamesis when trying to establish cause i.e. oesophageal varices (HPC)

A

Excessive alcohol consumption = cirrhosis -> varices, gastritis, peptic ulcer disease
Smoking - peptic ulcer disease, upper GI malignancy
IV drug use or tattoos - viral hepatitis -> cirrhosis

18
Q

What features might you look for inspection for haematemesis

A 
Tattoos, needle track marks, piercings (viral hepatitis)
Signs of liver disease
Purpurua 
Thoraco-abdominal scars
Cachexia
19
Q

What are the signs of liver disease on inspection

A 
Jaundice
Scratch marks
Bruising
Spider naevi >4
Palmar erythema 
Dupuytren's contracture
Gynaecomastia
Ascites
Ankle oedema
Caput medusae
20
Q

What might you find on abdominal examination for haematemesis

A

Hepatomegaly
Splenomgealy
Epigastric tenderness
Epigastric mass, Virchow’s node

21
Q

What might you find on digital rectal exam for haematemesis

A

Haemorrhoids (portal hypertension)

Melaena or haematochezia (GI bleed)

22
Q

What investigations should be arranged for suspected viral hepatitis and CLD

A

Viral hepatitis and HIV serology

Urinalysis (proteinuria)

23
Q

What is the management for patients while they await endoscopy

A

Regular observation (hourly, 30 min if low BP or high HR)
Nil by mouth 6 hrs before
IV fluids
Pro-kinetic e.g. erythromycin or metoclopramide (empties the stomach)
Correct coagulopathy and/or platelets if continuing to bleed

24
Q

What extra management options should be given to patients with a history of alcohol abuse and potential malnourishment

A

Thiamine to prevent Wernicke’s encephalopathy

Monitoring for alcohol withdrawal, give chlordiazepoxide and use CIWA-A

25
Q

What forms of imaging could be used if endoscopy failed to reveal the source of bleeding

A

Angiography (femoral catheter to inject contrast)

Laparotomy

26
Q

How is a bleeding oesophageal varix managed

A 
Endoscopic band ligation
Endoscopic scleropathy 
Balloon tamponade 
Transjugular intrahepatic portosystemic shunt (TIP or TIPSS)
Portocaval shunt (rare)
27
Q

What long-term management should be offered to patients for portal hypertension

A

Lifestyle advice (Stop smoking and drinking)
Reduce BP (beta blocker, isosorbide mononitrate)
Antibiotics (1 week to prevent sepsis)
TIPS/TIPSS
Encephalopathy treatment

28
Q

Haematemesis with dark clots, melaena, ibuprofen use, hypotensive and tachypnoeic
What is the main differential and next steps

A

Bleeding peptic ulcer

Bloods (FBC, clotting, U&Es, creatinine, LFTs, albumin)
Cross-match blood
Give fluids
CXR
OGD
29
Q

What is the management for a bleeding peptic ulcer found on OGD

A

Stop bleeding using endoscopic fibrin sealant and adrenaline injection around the ulcer
Omeprazole infusion after endoscopy
Do a biopsy of ulcer

30
Q

What is the management for a peptic ulcer caused by H. pylori

A

Triple therapy

PPI + 2 antibiotics

31
Q

28M with haematemesis and chest pain after eating spicy food and drinking lots of alcohol the night before. Was vomiting the night before. Vomited 6 times and vomited blood the last 2 times. Smokes. No epigastric pain or bowek changes. Purple appearance to his face due to burst superficial capillaries from vomiting
What is the differential and next step

A

Mallory-Weiss tear (after forceful vomiting)
Could also be Boerhaave’s perforation of the oesophagus (less likely if CXR is normal)

OGD needed

32
Q

42F vomiting copious amounts of blood. Was at a cocktail party when one noticed blood from her left nostril. She then vomited blood, and continues to do so on presentation. Blood is still coming out her left nostril after initial stabilisation

A

Epistaxis due to the blood coming from the nose
The blood is then falling back into the pharynx , causing the vomiting
Likely to be posterior nosebleed

33
Q

What are most episodes of epistaxis caused by and how are they resolved

A

Anterior nosebleeds from Little’s area (90%)
Ask patient to sit up with head leaning forward and pinch the front of the nose for 10 minutes (Trotter’s)
If this fails, spray with phenylephrine-containing spray or insert adrenaline-soaked gauze and reapply pressure
If that fails, use a nasal pack and refer to ENT

34
Q

What is the next management step after an anterior nosebleed has been stopped

A

Look for stigmata of bleeding that may be amenable to cautery (with silver nitrate sticks) under local anaesthetic spray
Discharge with naseptin or vaseline and avoid hot drinks

35
Q

Which type of nosebleed is more likely to result in haematemesis and from which artery does it stem from

A

Posterior nosebleeds from branches of the sphenopalatine artery

36
Q

How are posterior nosebleeds stopped

A

Urinary catheter with a balloon is inserted via the nose into the oropharynx, where the balloon is inflated and catheter pulled back
Refer to ENT

37
Q

What are the main risk factors for peptic uclers

A 
H. pylori 
Smoking
Alcohol
NSAIDs and aspirin
Blood group O
Hypercalcaemia
Physiological stress
Burns or brain trauma
38
Q

Why are alcoholics vulnerable to haematemesis

A
  1. Anatomy - liver becomes damaged and fibrosed, the circulation starts to bypass the liver (portosystemic anastamoses), occuring at the oesophagus (varices), umbilicus (caput medusae), rectum (varices), diaphragm, and retroperitoneum
  2. Physiology - risk of cirrhosis, impaired clotting factor production, bleeding tendency + irritation of the mucosa -> oesophagitis, gastritis, ulcers
  3. Behaviour - more prone to vomiting -> Mallory-=Weiss or Boerhaave’s perforation
39
Q

What is the Child-Pugh score

A 
Used to assess severity of liver cirrhosis 
Prognostic: 5-6 (class A) have 100% survival. 10-15 (class C) have 45% survival. 
Higher score -> portal hypertension, oesophageal varices
40
Q

What are the indications for packed red cell tranfusion in adults

A

Catastrophic haemorrhage
Hb <70 + signs of compromise
Hb < 80 + signs of compromise in patients >65

41
Q

What are the risks associated with blood transfusion

A 
Acute transfusion reaction
Anaphylaxis 
Haemolytic transfusion reaction
Transfusion-associated lung injury (TRALI)
Delayed haemolytic reaction 
Alloimmunisation 
Post-transfusion purpura
Transfusion-associated circulatory overload 
Coagulopathy 
Transfusion-transmitted infection

Y3 Oxford Cases (29 decks)

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