Haematemesis Flashcards
(12 cards)
Probability diagnosis
Chronic peptic ulcer (stomach and duodenum) 50%
Acute gastric ulcers/erosions 20%
Oesophagitis (incl. GORD)
Mallory–Weiss (emetogenic) syndrome
Drugs:
- aspirin
- NSAIDs
- anticoagulants
- clopidogrel
- NOACs
Causes of upper GI bleeding
The major cause of bleeding is chronic peptic ulceration of the duodenum and stomach,
- 50% of all cases.
The other major cause is acute gastric ulcers and erosions,
- 20% of cases.
Aspirin and NSAIDs are responsible for many of these bleeds.
Serious disorders not to be missed
Vascular:
- oesophageal varices
- blood dyscrasias, e.g. aplastic anaemia
- vascular malformation/angiodysplasia
- hereditary coagulopathy
Cancer:
- gastric or oesophageal
Other:
- chronic liver disease
Pitfalls (often missed)
Stomach ulcer
Swallowed blood (e.g. epistaxis)
Collagen diseases (e.g. scleroderma)
Rarities:
- ruptured oesophagus
- hereditary haemorrhagic telangiectasia
- scurvy
- ingested poisons (e.g. acid, alkali, arsenic)
- gastric antral vascular ectasia
Key history
Nature of vomitus from fresh blood to ‘coffee grounds’
Is bleeding arising from the mouth, nose or pharynx?
Indigestion, heartburn or stomach pains
Associated symptoms (e.g. weight loss, jaundice)
Any bleeding problems
Drug history including;
- alcohol
- NSAIDs
- antiplatelet agents
- warfarin
- steroids
Key examination
Pt’s general state including circulation, vital signs
Abdo exam and rectal exam
Evidence of liver disease
Key investigations
Upper GIT endoscopy diagnoses bleeding source in 80%
FBE
LFTs including © GT
Helicobacter pylori tests
Imaging (e.g. plain erect X-ray, as indicated)
Diagnostic tips
Melaena occurs in 50% of cases of haematemesis.
Oesophageal bleeding tends to give vomiting fresh blood.
‘Coffee grounds’ vomitus indicates contact with gastric acid.
Acute severe upper gastrointestinal haemorrhage is an important medical emergency!!
A sudden loss of 20% or more circulatory blood volume usually produces signs of shock, such as:
- tachycardia
- hypotension
- faintness and
- sweating.
Management
The immediate objectives are:
- restore an effective blood volume (if necessary)
- establish a diagnosis to allow definitive treatment
All pts with a significant bleed should be admitted to hospital and referred to a specialist unit.
Urgent resuscitation is required where there has been a large bleed and there are clinical signs of shock, require
- an intravenous line inserted and
- transfusion with RBC or fresh frozen plasma (or both)
PPIs should be commenced in most cases since most bleeds are from peptic ulceration.
Use oral PPIs if possible but IV PPIs can be used.
In some instances haemostasis of bleeding points (via endoscopy) can be achieved with:
- a heater probe (e.g. Gold Probe) or
- injection of adrenaline or both.
Occasionally surgery will be necessary to arrest bleeding but should be avoided if possible in pts with acute gastric erosion.
Practical points
In many pts bleeding is insufficient to decompensate the circulatory system and they settle spontaneously
85% stop within 48 hrs
