Haematemesis

Question 1

Emergency causes of haematemesis

Answer 1

Oesophageal varcies

Gastric ulceration

Question 2

Non-emergency causes

Answer 2

Mallory-Weiss tear

Oesophagitis

Gastritis

Gastric malignancy

Meckel’s diverticulum

Vascular malformations like Dieulafoy lesions

Question 3

Explain oesophageal varices

Answer 3

Dilations of the porto-systemic venous anastomoses in the oesophagus

The veins are swollen, thin and prone to rupture.

This can lead to catastrophic haemorrhage

Question 4

Causes of oesophageal varices

Answer 4

Portal HTN from alcoholic liver disease

Any haematemesis in a patient with known history of alcohol abuse should be investigated with an urgent OGD

Question 5

Explain gastric ulceration

Answer 5

Responsible for around 60% of haematemesis cases

The ulceration leads to erosion into blood vessels most commonly lesser curve of stomach or posterior duedenum.

This can cause significant hamorrhage

Question 6

Causes

Answer 6

Active ulcer disease/H. pylori positive

History of NSAID or steroid use

Previous epigastric symptoms suggesting peptic ulceration

Question 7

Explain Mallory-Weiss tear

Answer 7

Relatively common phenomenon with severe or recurrent vomiting and followed by minor haematemesis

The forceful vomiting causes a tear in the epithelial lining of the oesophagus that can lead to a small bleed

Question 8

Management of Mallory Weiss tears

Answer 8

They are benign usually and resolve spontaneously.

Reassurance and monitoring should suffice

Prolonged or worsening haematemesis warrants investigation with an OGD

Question 9

Explain oesophagitis

Answer 9

Inflammation of the intraluminal epithelial layer of the oesophagus.

This is usually due to GORD or infections like candida albicans or bisphosphonates, radiotherapy, ingestion of toxic substances or Crohn’s disease.

Question 10

Key facts to ascertain in clinical features

Answer 10

Timing, freq, volume of bleed

Hx of dyspepsia, dysphagia, odynophagia

PMH, smoking, alcohol

Use of steroids, NSAIDs, anticoagulants, bisphosphonates

Question 11

Laboratory tests

Answer 11

Routine bloods with FBC, U&Es and clotting

VBG should also be done

G&S

Question 12

Lab test findings

Answer 12

Acute bleed may not show anaemia initially

LFTs might be elevated in underlying liver damage as a potential cause

Question 13

Definitive diagnostic investigation.

Answer 13

OGD which also forms part of the management if the bleed is unstable.

This should be performed within 12hs or ASAP if patient is unstable.

eCXR might be done to check for perforated peptic ulcer as well.

Ct abdo with IV contrast can be useful to assess active bleeding in an unstable patient, especially if endoscopy is unremarkable.

RBC Scintigraphy can also be done

Question 14

What scoring system is used to stratify risk in upper GI bleed?

Answer 14

Glasgow-Blatchford Bleeding score (GBS)

Question 15

Explain GBS

Answer 15

Based purely on clinical and biochemical parameters

Allows for approriate management and further investigations.

Scores of 6 or more have a >50% risk of needing and intervention

Question 16

What other scoring systems might be used?

Answer 16

AIMS65 = risk score for in-hospital mortality of upper GI bleed

Rockall score = severity score for GI bleed post-endoscopy

Question 17

Initial management

Answer 17

Since they can be extremely unstable the first step is rapid ABCDE assessment + insertion of two large bore IV cannulas

Start fluid resus + corssmatch blood

Most cases also need OGD

Question 18

Specific management of peptic ulcer disease

Answer 18

Injections of adrenaline and cauterisation of the bleed

High dose IV PPi therapy (40mg IV omeprazole) to reduce acid secretion +/- H.pylori eradication therapy if necessary.

Question 19

Specific management of oesophageal varices

Answer 19

Should be done at the same time as active resus.

Endoscopic banding is the most definitve method, but can prove difficult.

Somatostatin analogues like octreotide or vasopressors like terlipressin should be started.
This acts to reduce splanchnic blood flow and hence reduce bleeding

Long term management warrants repeated banding of the varices and long-term beta-blocker therapy

Question 20

What general intervention can be done in any active bleed

Answer 20

Angio-embolisation in which the bleeding vessel is embolised.

This is most commonly the gastro-duodenal artery.

Question 21

When might sengstaken-blakemore tube be used?

Answer 21

In severe cases of oesophageal varices and is inserted to the level of the varices and inflated to compress the bleeding.