Haematemesis

Question 1

Describe the immediate management of a patient who has lost a lot of blood.

Answer 1

ABCDE

Question 2

What landmark defines the terms ‘upper GI’ and ‘lower GI’?

Answer 2

The ligament of trietz (this is towards the distal end of the duodenum)

Question 3

List the differential diagnosis for haematemesis.

Answer 3

Oesophagitis/gastritis/duodenitis
Bleeding peptic ulcer 
Oesophageal varices 
Mallory-Weiss tear 
Gastric cancer
Oesophageal cancer 
Arteriovenous malformation

Question 4

What is haematemesis?

Answer 4

vomiting blood

Question 5

Describe two additional components in the management of upper GI bleeds that are caused by oesophageal varices.

Answer 5

Terlipressin 1-2 mg, 4-6 hourly

Prophylactic antibiotics

Question 6

Describe the two scoring systems for upper GI bleeds.

Answer 6

Glasgow-Blatchford – stratifies patients presenting with upper GI bleeds into low and high-risk categories. It is independent of endoscopy.
Rockall – involves a more comprehensive assessment of haematemesis. It is used to predict risk of re-bleeding and mortality. Based on age, shock, comorbidities and endoscopy findings.

Question 7

When is emergency endoscopy indicated?

Answer 7

Unstable patient with severe acute upper GI bleeding immediately after resuscitation
Suspicion of ongoing upper GI bleed and Glasgow-Blatchford > 6
Patients with a previous aortic graft to exclude aorto-enteric fistula

Question 8

Other than OGD, list two other useful investigations for upper GI bleeds.

Answer 8

Erect CXR
Perforated peptic ulcer may cause haematemesis and pneumoperitoneum
A left-sided pleural effusion may be seen in Boerhaave’s perforation
CT Chest/Abdomen

Question 9

Which investigation does all patients with aortic grafts need?

Answer 9

Contrast CT aortogram to rule out aorto-enteric fistula

Question 10

List some questions that are important to ask patients presenting with upper GI bleeds.

Answer 10

How much blood was there?
What did the blood look like? (Fresh or coffee grounds)
Has there been any blood in the stool?
Did vomiting trigger the haematemesis?
Has there been any recent weight loss? (malignancy)
Have you had any problems swallowing? (oesophageal malignancy)
Have you experienced easy bruising, abdominal distension, puffy ankles or lethargy? (liver failure)
Has there been any epigastric pain?

Question 11

Why is it important to ask about the character of the blood?

Answer 11

Fresh blood suggests upper GI bleed

Coffee grounds vomit suggests that the blood has been partially digested by stomach acids

Question 12

What is the difference between melaena and haematochezia?

Answer 12

Melaena – caused by upper GI bleeds and digestion of the blood during GI transit
Haematochezia – fresh blood in stools
Usually caused by lower GI haemorrhage or by profuse upper GI bleed or if GI transit times are rapid

Question 13

Why is it important to ask whether vomiting triggered the haematemesis?

Answer 13

Forceful vomiting can cause Mallory-Weiss tears and Boerhaave’s perforation, which lead to haematemesis

Question 14

List some key features that you should look out for in the past medical history.

Answer 14

Previous upper GI haemorrhage
Heartburn or epigastric pain (may suggest peptic ulcer disease or oesophagitis/gastritis/duodenitis)
History of GORD (can lead to oesophageal cancer)
Aortic repair with grafts
Bleeding tendency
Chronic liver disease

Question 15

List some key features that you should look out for in the drug history.

Answer 15

Anticoagulants
Drugs that increase risk of PUD (e.g. NSAIDs, aspirin, bisphosphonates, steroids)
Drugs that cause liver toxicity (e.g. methotrexate, amiodarone)
Beta-blockers (can mask signs of shock)

Question 16

List some key features that you should look out for in the social history.

Answer 16

Excessive alcohol consumption (risk of cirrhosis and PUD)
Smoking (risk of PUD and GI malignancy)
IV drug use and tattoos (risk of viral hepatitis)

Question 17

Why is it important to take note of any needle track marks and piercings on physical examination?

Answer 17

They are both risk factors for viral hepatitis

Question 18

List some signs of liver disease on examination.

Answer 18

Jaundice 
Scratch marks 
Spider naevi
Bruising 
Palmar erythema
Dupuytren’s contracture 
Gynaecomastia 
Ascites 
Ankle oedema

Question 19

What does purpura suggest?

Answer 19

Thrombocytopenia

Question 20

List some significant signs that could be found on palpation and state what they suggest.

Answer 20

Splenomegaly – can be a sign of portal hypertension
Epigastric tenderness – can suggest PUD or gastritis/duodenitis
Virchow’s lymphadenopathy – suggests GI malignancy

Question 21

List some significant signs that could be found on DRE and state what they suggest.

Answer 21

Haemorrhoids – could be a consequence of portal hypertension
Melaena or haematochezia – confirms GI bleed

Question 22

List some features of liver disease in the blood results.

Answer 22

Macrocytic anaemia 
Low albumin
Raised liver enzymes 
Raised bilirubin 
Raised GGT 
Prolonged clotting times 
Raised urea

Question 23

List some causes of macrocytic anaemia.

Answer 23

B12 deficiency
Folate deficiency
Alcoholism

Question 24

List some causes of low albumin.

Answer 24

Chronic liver failure
Malnutrition
Malabsorption
Nephrotic syndrome

Question 25

What derangement of the liver function tests is consistent with alcohol abuse?

Answer 25

Raised GGT in the absence of raised ALP

Question 26

What does raised urea in the context of normal renal function suggest?

Answer 26

It suggests that the patient has had a ‘protein meal’ of some form – which is most likely to be due to the digesting of red blood cells

Question 27

What other investigations may be useful in patients with upper GI bleeds?

Answer 27

Viral hepatitis and HIV serology

Urinalysis (may show proteinuria, which, in the context of hypoalbuminaemia, would suggest nephrotic syndrome)

Question 28

Describe the management of a patient awaiting endoscopy.

Answer 28

Regular observation 
NBM
IV fluids 
Pro-kinetic drugs (e.g. erythromycin, metoclopramide) 1 hour before endoscopy 
Correct coagulopathy/platelets

Question 29

State two important complications of alcoholism that you must bear in mind when taking care of an alcoholic patient.

Answer 29

Thiamine – prevents Wernicke-Korsakoff syndrome

Withdrawal – prescribe chlordiazepoxide

Question 30

Other than endoscopy, list two other ways of visualising a bleed.

Answer 30

Angiography

Laparotomy

Question 31

List three methods of stopping the bleeding from oesophageal varices.

Answer 31

Endoscopic band ligation 
Injection sclerotherapy 
Balloon tamponade (Sengstaken-Blakemore tube or Minnesota tube)

Question 32

State and describe a surgical technique used to relieve portal hypertension.

Answer 32

Transjugular intrahepatic portosystemic shunt (TIPS)

NOTE: this is an intrahepatic connection between the portal vein and the hepatic vein

Question 33

Describe an important complication of portacaval shunting.

Answer 33

It can trigger hepatic encephalopathy because toxins are bypassing the liver and entering the systemic circulation

Question 34

Briefly describe the long-term management of portal hypertension.

Answer 34

Lifestyle: stop drinking alcohol and smoking 
Maintain low blood pressure 
Antibiotics 
TIPS
Treat hepatic encephalopathy

Question 35

What is commonly used to treat hepatic encephalopathy?

Answer 35

Lactulose and phosphate enemas

They decrease GI transit time and minimise GI absorption

Question 36

Which type of nosebleed can present with haematemesis?

Answer 36

Posterior nose bleeds