Haematemesis Flashcards
What is the sign for pneumoperitoneum on a cxr?
Cupola sign = cup like dome (architectural etymology)
Haematemesis vs haematochezia vs melena
Haematemesis = vomiting blood Haematochezia = fresh blood per anus Melena = dark stool (blood is mixed)
Questions to ask about PC
How much blood was vomited? Character of blood (colour) Any blood in stool, if so what colour? Did forceful coughing trigger it? Any lethargy/ankle swelling/easy bruising/distended abdomen? Recent weight loss? Problems swallowing? Epigastric pain?
What would a coughing trigger suggest?
Malory-weiss tear or boehaave’s perforation
What is a malory weiss tear?
A lesion/tear in the lining of the oesophagus, resulting in bleeding
What might be the character of epigastric pain that suggests gastric carcinoma?
Gnawing/achey
What might be the character of epigastric pain that suggests GORD
Episodic dyspepsia
PMH key questions/conditions that might be relevant
GORD Peptic ulcer Cirrhosis Aortic graft Helicobacter pylori Hx of cancer Bleeding tendency/clotting issues
Why is GORD relevant?
Chronic GORD -> oesophagitis -> Barret’s oesophagus -> adenocarcinoma
Histology of Barret’s oesophagus
Metaplastic change of oesophageal epithelium from stratified squamous to simple columnar, resembling the intestine’s goblet cells
What does metaplastic change mean?
Reversible change
Drugs that might be relevant and why
Beta blockers - might mask signs of shock and prevent tachycardia in a hypovolemic patient
Methotrexate - liver toxicity
NSAIDs - gastric irritation
Name some drugs that can lead to peptic ulcer disease
Bisphosphonates Steroids Clopidogrel Aspirin NSAIDS
CAGE questions
Have you ever thought about CUTTING down your drinking?
Anyone been ANNOYED at you for drinking?
Ever felt GUILTY for drinking?
Ever opened your EYES in the morning and felt like you needed a drink to get over a hangover? (eye-opener)
Dfx
Peptic ulcer Oesophageal varices Gastric/oesophageal cancer Angiodysplasia Mallory-Weiss tear Gastrointestinal stromal tumour
What is angiodysplasia? How do you differentiate this from everything else?
Abnormal formation of the blood vessels in the gut - not painful
How bad is the haematemesis in oesophagitis/mallory weiss?
Oesophagitis and Mallory-Weiss tears are unlikely to result in significant haematemesis
Three key investigations
LFT
Coagulation studies
Blood glucose
Immediate management of vomiting
IV vasopressin analogue (terlipressin)
IV antibiotics
Refer to oncall endoscopy
Fluid resus with blood transfusion
Two treatment options for oesophageal varices - explain what these are
Band ligation (literally putting a rubber band around the bulge so it doesn’t burst
Or sclerotherapy (injecting something that causes veins to shrink)
What is used as the last resort?
Sengstaken-Blakemore tubes (balloon inflation)
What else can be done? Explain this procedure
TIPPS (Transjugular, intrahepatic, portosystemic shunt)
Essentially creates a shunt between the portal vein and the jugular vein, bypassing the hepatic veins in order to relieve the portal pressure
