Haematemesis and Melaena

Question 1

Causes of H & M

Answer 1

4 most common:
1. Peptic ulceration
2. Oesophageal and Gastric varices 
3. Erosions: gastritis, esophagitis, duodenitis
4. Mallory Weiss tear
Other:
5. Tumour
6. AV malformations
7. Aorto-enteric fistulae (suspect in ANY patient who has had an aortic graft)
8. Bleeding disorders

Question 2

Appearance of vomitus in haematemesis?

Answer 2

Upper GIT bleeding is manifested by frank haematemesis or coffee ground vomitus

Question 3

What is the traditional definition of haematemesis?

Answer 3

Bleeding of the GIT proximal to the ligament of trietz, at the distal end of the duodenum

Question 4

T/F all patients with malaena should be admitted

Answer 4

True

Question 5

Important points of Hx?

Answer 5

1. Alcohol
2. Drugs, especially warfarin, aspirin, NSAID use, Fe tablets can turn stools black
3. Estimate of blood loss
4. Past history in particular:
   a. any previous GIT bleeds and diagnosis given for these, particularly variceal bleeding
   b. liver disease
   c. aortic graft surgery
   d. any significant co-morbidities

Question 6

Important points of Px?

Answer 6

1. ABC, assessment, signs of shock or postural drop (> 20mmHg)
2. Signs of anaemia (conjunctival pallor)
3. General and abdominal examination for signs suggesting the possibility of variceal bleeding:
   a. CLD (jaundice, spider naevi, gynecomastia)
   b. Portal HTN (splenomegaly, ascites)
4. PR for detection of malaena

Question 7

Conjunctival pallor generally indicates a Hb of less than —-?

Answer 7

Conjuctival pallor generally indicates Hb less than 10gms/dL (deci Litre)

Normal results for adults vary, but in general are:
Male: 13.8 to 17.2 grams per deciliter (g/dL)
Female: 12.1 to 15.1 g/dL

Question 8

What can be inferred from a negative PR exam? If there is still uncertainty but have high clinical suspicion, what should be done?

Answer 8

Negative PR exam does not rule out GIT bleed, especially if it is recent. Similarly, a lack of overt haematemesis does not necessarily rule out a GIT bleed

If uncertainty remains, and clinical suspicion is high, then NGT may be placed to look for the presence of fresh upper GI bleed.

The presence of varices is a C/I to NG tube, but if there is no suspicion of varices or potral HTN, then it may be considered

Question 9

Ix of H & M?

Answer 9

1. Blood tests:● FBE.● U&ES / glucose.● LFTs.● Clotting profile● X-matching of blood (2-4 units according to the clinical picture).● FFP and platelets should also be ordered if bleeding is severe or the patient has a coagulopathy.
2. ECG.
3. CT scan● If aortic-enteric fistula is suspected, then an urgent CT scan will be required.
4. CXR
5. Occult blood testing:● If there is doubt over whether “coffee grounds” represents blood, or if a patient is taking iron tablets causing uncertainty regarding the presence of melena, then samples may be sent to pathology to be tested for the presence of blood.

Question 10

Initial Management of H & M

Answer 10

1. Usual ABC measures and NBM
2. Two large bore IV cannulae placed and appropriate fluid resuscitation commenced (usually bolus 1-2 L crystalloid)● Both lines must be of the “pump” set type, so that fluid can be pumped through by hand if necessary.● Rapid infusion devices may be necessary in very severe cases.
3. Treat coagulopathy: with Vitamin K, FFP (if thrombocytopaenia of platelets

Question 11

Which patients are the ‘at risk patients’ that require blood products, FFP and platelets early?

Answer 11

At risk patients include:

●	Chronic liver disease.  

●	Uremic patients

●	Patients with blood dyscrasias, including thrombocytopenia.

● Patients on medications that affect coagulation, asprin / NSAIDS and in particular those on warfarin.

Any patient with significant GI bleeding who is on warfarin should receive Prothrombinex-HT as early as possible, even without waiting for results of investigations. Recommended dose is 2,000 to 3,000 units (4 - 6 vials)

Question 12

Management of Peptic Ulcer Bleed

Answer 12

Alongside initial management:
1. PPI: in cases of BLEEDING PEPTIC ULCERS.
IV PPI infusions have been shown to reduce risk of ulcer re-bleeding in patient at high risk:

a. Those with endoscopic stigmata of recent haemorrhage: visible vessel and/ or clot on ulcer base
b. Those with active bleeding even after endoscopic therapy

Options of PPI:
80 g IV as a bolus over 15-30minutes, then 8mg/hour by IV infusion for up to 3 days of either:

• Pantoprazole (Somac)
• Esomeprazole (Nexium)
• Omeprazole

2. ENDOSCOPIC MANAGEMENT
   A. When do we scope? The urgency of the endoscope in non-variceal bleeds may be guided by the clinical Rockall score of the patient
   - Scopes are non-urgent (done in

Question 13

Management of gastro-oesophageal variceal bleed

Answer 13

1. OCTREOTIDE (somatostatin analogue)

if OESOPHAGEAL VARICES suspected give,
Octreotide 50 micrograms IV immediately, then
25 to 50 micrograms per hour by IV infusion for 2-5 days

MoA: Octreotide decreases glucagon release -> decrease vasodilatation -> decrease portal flow -> decrease portal HTN

Other Rx: Terlipressin

2. ANTIBIOTICS: cephalosporin
3. ENDOSCOPIC MANAGEMENT
   If oesophageal varices bleed: oesophageal banding (shoot rubber band around varice vessel, it scleroses over time and falls off)
   If gastric varices bleed: gastric variceal gluing
   If uncontrollable in either: insert a Minnesota tube or Sengstakene and Blakemore tube and inflate balloon to compress bleed
4. If banding or gluing fails: TIPS (Transjugular intrahepatic portosystemic shunt) - surgical pathway made between IVC and portal vein (bypass liver)

Question 14

Prevention and follow up management of H & M

Answer 14

1. H pylori eradication (in cases of PUD)
2. PPI
3. Attention to underlying factors: NSAIDs, alcohol, smoking