Haematemesis (oxford clin cases) Flashcards
How is shock defined medically?
BP < 90/60 mmHg
How is shock treated medically?
Fluid resuscitation
What are the common causes of haematemasis?
Oesophagitis/ duodenitis/gastritis
Varices
Bleeding peptic ulcer
What are some other causes of heamatemasis (asides from common causes)
Mallory-Weiss tear
Bleeding of upper GI cancer
Ateriovenous malformation
How may someone with gastric cancer present?
Abdominal pain Haematemesis Dysphagia Weight loss Lymphadenopathy
In what patients is gastric cancer more common?
Age 50-70
Males
Smokers
Those with a family history
What are first line investigations for gastric cancer?
First line= upper GI endoscopy with biopsy
Once diagnosis is confirmed= endoscopic ultrasound to stage and Ct abdomen and pelvis/chest x ray to look for mets
Also do bloods to check for anaemia, LFTs/kidney function incase of mets
How is gastric cancer managed?
In early stages there should be surgical resection with perioperative chemo and postop chemoradiation
If a patient does not want surgery then chemoradiation
If late stage then chemoradiation and palliative care eg palliative gastrectomy
What are some risk factors for gastric cancer?
Pernicious anaemia
H pylori infection
Diet low in fruits and vegetables
What scoring system may be used to calculate risk of patients with haematemesis deteriorating and to help decide the course of treatment?
Blatchford or Rockall
What does fresh blood during haematemasis indicate?
Upper GI bleed
What does ‘coffee ground’ blood during haematemasis indicate?
Blood that has been partially digested by the stomach acid
What does melaena suggest?
Upper GI bleed where blood has been digested
What does haematemasis triggered by forceful vomitting suggest could be the problem?
Beorhaave’s perforation
What does haematemasis with weight loss suggest?
Malignancy
What does haematemasis with dysphagia suggest?
Oesophageal malignancy
What is cirrhosis?
The pathological end stage of liver disease, it involves the fibrosis and conversion of liver calls into nodules
How will someone with cirrhosis present?
Abdominal distention Jaundice and pruritus Haematemesis Melaena Ascites Spider naevi Palmar erythema Leukonychia
What are first line investigations for cirrhosis?
LFTs GGTs Serum sodium Serum albumin Prothrombin time
How is cirrhosis managed?
By treating the underlying cause and complications eg antivirals for hep C, diuretics and low sodium diet for ascites etc
What are the causes of cirrhosis?
Hep B
Hep C
Alcoholic liver disease
Non alcoholic fatty liver disease
What are some symptoms of liver failure?
Haematemesis Easy bruising Distended abdomen Puffy ankles Lethargy
What are some questions to ask in the history if someone has haematemesis? Why are you asking these questions?
How much blood do they vomit?
When do they vomit blood?- eg after forceful vomitting?
What does the blood look like in colour?- is it fresh and red or brown coloured
Is there any blood in the stools?- melaena?
Have they had recent weight loss?- alerts you to carcinoma
Is there dysphagia?- oesophageal cancer
Do they have symptoms of liver failure eg lethargy, puffy ankles, easy bruising, distended abdomen
What should you suspect as a cause of haematemesis if someone is on NSAIDs?
Peptic ulcer disease
What will tattoos/needle track marks/ piercings suggest could be a cause of haematemesis?
Chronic viral hepatitis
What is Wernicke’s encephalopathy caused by?
Thiamine deficiency
How will someone with Wernicke’s encephalopathy present?
Confusion
Reduced vestibulo-ocular reflexes
Mental slowing
Impaired concentration
Why are alcoholics at risk of Wernicke’s encephalopathy?
They usually have a poor diet which causes them to be deficient in thiamine
Chronic alcohol use also causes problems absorbing thiamine
What investigations are done for Wernicke’s encephalopathy?
Therapeutic trial of parentral thiamine
Bloods looking at FBC, LFTs, kidney function
Serum electrolytes
Blood glucose via finger prick test
How is Wernicke’s encephalopathy managed?
By giving thiamine supplements, magnesium (if they are deficient), and multivitamins
How will someone with a bleeding peptic ulcer present?
Haematemesis (blood will be coffee ground coloured usually due to partial digestion by stomach acid)
Melaena
Tachypnoea
Low blood pressure
What should you think when someone comes in with haematemesis and takes NSAIDs?
Bleeding peptic ulcer
What is the first line investigation for someone with a bleeding peptic ulcer?
Upper GI endoscopy
How do you treat a bleeding peptic ulcer?
Blood transfusion if needed PPIs H pylori eradication therapy Tell them to stop taking NSAIDs Supportive treatment eg IV fluids
Why might alcoholics have a higher tendency to bleed?
Damage to the liver means less clotting factors are produced
Damage to the liver and fibrosis forces blood to take alternate routes- this leads to the formation of portosystemic anastamoses
What score is used to assess severity of liver cirrhosis?
Child-Pugh score
What part of the clotting pathway does liver disease affect?
Extrinsic pathway
Why is it important to ask if someone who present with haemetemesis is taking beta blockers?
They can mask the effect of shock but slowing the heart rate down
What type of anaemia is common in alcoholics? Why?
Macrocytic- the mechanism is unknown
What type of anaemia will someone with alcohol abuse likely present with?
Macrocytic
It may also be a mixed picture because if they are iron deficient
