Haematemesis and Malaena

Question 1

what is haematemesis?

Answer 1

medical emergency

vomiting of blood from upper GI tract

Question 2

types of haematemesis?

Answer 2

bright red blood or clots = active bleeding

altered blood/coffee-grounds blood = bleeding has stopped or has been relatively modest

Question 3

what causes malaena?

Answer 3

upper GI haemorrhage

black appearance caused by oxidation of iron in the haemoglobin as it passes through the ileum and the colon

Question 4

risk factors for haematemesis and malaena?

Answer 4

age >50
NSAID use
excessive alcohol
smoking
any serious illness
radiation
excess acid production

Question 5

causes of upper GI bleed?

Answer 5

oesophagitis 
peptic ulcer (NSAIDs, H pylori)
vascular malformations
aorto-duodenal fistula
varices
mallory weiss tear
stomach/oesophagus cancer
gastric erosions (NSAIDs, alcohol)

Question 6

how can risk of re-bleeding and death after upper GI bleed be scored?

Answer 6

rockall score
depends on age, shock, comorbidity, diagnosis and amount of haemorrhage
score <3 = good prognosis
score >8 = high risk of mortality

Question 7

emergency management of haematemesis / malaena?

Answer 7

ABCDE
IV access/IV fludis
cross match +/- transfusion if Hb <7
venous pressure monitoring 
bladder catheterisation 
PPI 80mg bolus followed by 8mg/hr infusion
OGD (oesophago-gastro-duodenoscopy) immediate/urgent 
anticoagulation potentially

Question 8

how is bleeding peptic ulcer managed?

Answer 8

endoscopic therapy: bipolar electro coagulation or heater probe or injection therapy (alcohol/adrenaline) or clips

if bleeding continues: high dose constant infusion of IV PPI (80mg bolus then constant 8mg /hr infusion) then reattempt endoscopic therapy
if bleeding stops after 1st endoscopic therapy then give same PPI treatment anyway

Question 9

emergency management of variceal bleeding?

Answer 9

0.9% saline
vasopressor
prophylactic antibiotics
emergency endoscope 
variceal-band ligation 
PPI
phosphate enema/lactulose enema

Question 10

management of oesophageal varices?

Answer 10

resus, antibiotics, vasoconstrictors - IV terlipressin infusion at 2mg every 6 hrs and do early OGD +/- EVL (endoscopic variceal ligation)
if bleeding continues do EVL or balloon tamponade AKA SB tube (triple or 4 lumen tube with oesophageal and gastric balloons)
if bleeding continues do TIPSS
also a role of sclerotherapy

Question 11

what is mallory weiss tear?

Answer 11

longitudinal tear at gastro-oesophageal junction which is induced by repetitive and strenuous vomiting

Question 12

management of mallory weiss tear?

Answer 12

usually stops spontaneously
endoscopic therapy if actively bleeding
angiographic therapy with embolisation or operative therapy with sewing of the tear can be done but rarely needed

Question 13

how can gastritis be managed?

Answer 13

avoid long term use of alcohol, NSAIDs, coffee, fatty foods and drugs
reduce stress
H2 blockers and PPIs

Question 14

how is H pylori related gastritis managed?

Answer 14

triple therapy: 2 antibiotics + 1 PPI

Question 15

aortic enteric fistula should be considered in which cases?

Answer 15

any patient with haematemesis and malaena that cannot be otherwise explained

Question 16

how is aortic enteris fistula managed?

Answer 16

surgical

Question 17

how is recurrent bleeding prevented?

Answer 17

eradication of H pylori
stop NSAIDs and acids
if NSAIDs have to be used, the use alongside PPI
use selective COX-2 inhibitors like coxib or traditional NSAIDs + coxib
coxib + PPI can further decrease ulcers and recurrent bleeding

Question 18

management pathway in suspected variceal haemorrhage?

Answer 18

• consider IV octreotide, broad spectrum antibiotics and beta blockers
• perform urgent oesophago-gastro-duodenoscopy with endoscopic variceal ligation banding
• if rebleeding occurs consider TIPSS or surgery

Question 19

management pathway in peptic ulcer bleeding?

Answer 19

endoscopic therapy with epinephrine and either thermocoagulation or clips

• if bleeding stops continue PPI and eradicate H pylori if present
• if rebleeding occurs attempt endoscopic therapy again, if bleeding continues then do arteriography with embolissation and consider surgery with severe ongoing bleeding

Question 20

management pathway in AV malformation or mallory weiss tear?

Answer 20

endoscopic therapy with epinephrine, thermo-coagulation or clips

Question 21

management pathway in erosive oesophagitis?

Answer 21

continue PPI

Question 22

class 1 shock?

Answer 22

<750ml blood loss
0-15% blood loss
no BP change
slight tachycardia 
normal resp rate and mental state

Question 23

class 2 shock?

Answer 23

750-1500ml blood loss
15-30% blood loss
raised diastolic BP
tachycardic 
normal resp rate

Question 24

class 3 shock?

Answer 24

1500-2000ml blood loss
30-40% blood loss
reduced BP
thready and tachycardic HR
raised resp rate
anxious, aggressive or drowsy

Question 25

class 4 shock?

Answer 25

>2L blood loss
>40% blood loss
very reduced BP
very tachycardic and thready HR
raised resp rate
drowsy, confused or unconscious