Haematemesis Flashcards
Emergency causes of haematemesis
Oesophageal varcies
Gastric ulceration
Non-emergency causes
Mallory-Weiss tear
Oesophagitis
Gastritis
Gastric malignancy
Meckel’s diverticulum
Vascular malformations like Dieulafoy lesions
Explain oesophageal varices
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
Causes of oesophageal varices
Portal HTN from alcoholic liver disease
Any haematemesis in a patient with known history of alcohol abuse should be investigated with an urgent OGD
Explain gastric ulceration
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
Causes
Active ulcer disease/H. pylori positive
History of NSAID or steroid use
Previous epigastric symptoms suggesting peptic ulceration
Explain Mallory-Weiss tear
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
Management of Mallory Weiss tears
They are benign usually and resolve spontaneously.
Reassurance and monitoring should suffice
Prolonged or worsening haematemesis warrants investigation with an OGD
Explain oesophagitis
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.
Key facts to ascertain in clinical features
Timing, freq, volume of bleed
Hx of dyspepsia, dysphagia, odynophagia
PMH, smoking, alcohol
Use of steroids, NSAIDs, anticoagulants, bisphosphonates
Laboratory tests
Routine bloods with FBC, U&Es and clotting
VBG should also be done
G&S
Lab test findings
Acute bleed may not show anaemia initially
LFTs might be elevated in underlying liver damage as a potential cause
Definitive diagnostic investigation.
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
What scoring system is used to stratify risk in upper GI bleed?
Glasgow-Blatchford Bleeding score (GBS)
Explain GBS
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
What other scoring systems might be used?
AIMS65 = risk score for in-hospital mortality of upper GI bleed
Rockall score = severity score for GI bleed post-endoscopy
Initial management
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
Specific management of peptic ulcer disease
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.
Specific management of oesophageal varices
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
What general intervention can be done in any active bleed
Angio-embolisation in which the bleeding vessel is embolised.
This is most commonly the gastro-duodenal artery.
When might sengstaken-blakemore tube be used?
In severe cases of oesophageal varices and is inserted to the level of the varices and inflated to compress the bleeding.
