Haematemesis

Question 1

What classifies Upper Vs Lower GI bleed?

Answer 1

Haematemesis is the presence of blood in the vomit that orginates above the ligament of treitz (oesophagus, stomach and duodenum)

Question 2

Main causes?

Answer 2

• Oesophageal varices 2nd to liver disease
• Ulcers (H pylori/NSAIDS)
• Malignancy

Risk factors: anticoagulant/antiplatelet meds

Question 3

Key things to ascertain in Hx

Answer 3

Hx
Volume of blood lost
Number of episodes
Assoc symps
Malignancy red flags

PMHx: liver disease / drugs
SHx: alcohol use

Question 4

Examination?

Answer 4

ABCDE

Question 5

Main concern to worry about when assessing a bleeding patients?

Answer 5

signs of shock

Question 6

Bloods

Answer 6

• FBC, U&Es (raised urea suggests digestion of blood)
  
  • LFTs
  • VBG (looks for lactic acidosis indicating shock)
  • Clotting factors
  • 2 group and saves.

Question 7

Imaging?

Answer 7

CXR - bowel perf

Question 8

Definitive investigation and management

Answer 8

UGI endoscopy

Question 9

Scoring systems to assess severity of bleed

Answer 9

ROCKALL
Glasgow-Blatchford

Question 10

Treatment

Answer 10

IV fluids
Transfusion according to criteria
- Blood + additional products (FFP aka clotting factors, platelets)
- Anticoagulation reversal

Question 11

Varices specific Tx

Answer 11

Broad spec IV Abx
Terlipressin - vasoconstrictor which reduces portal hypertension and varices (CI in heart disease - so watch out!)

Question 12

Endoscopic therapeutic techniques

Answer 12

Band-ligation
Clipping
Injections of “sclerosants” which irritate blood vessels and cause them to swell up
Thermal coagulation

Question 13

Time frame for endoscopy?

Answer 13

24 hrs maximum is the standard if not emergency/immediate

Question 14

If endoscopy fails?

Answer 14

TIPS by IR or Surgery

Question 15

If ulcer cause?

Answer 15

PPI post endoscopy

Question 16

Severity of bleed?

Answer 16

Class 1) <750 ml,

Class 2) 750-1500 ml

Class 3) 1500-2000 ml

Class 4) >2000 ml

Different indicators:
- BP can be preserved until late on

• Pulse increases with severity but becomes more thready (increased pulse is one of the first signs)
• Increased resp rate is another late sign
• Patient becomes thirsty in class 1, anxious or agrressive in 2/3 and drowsy and confused in class 4