define hematemesis, which organs can bleeding come from, how may the colour/vol of the vomit be helpfu;
- Haematemesis is the vomiting of blood.
- This condition occurs when there is bleeding in the oesophagus, stomach or duodenum, i.e. bleeding proximal to the duodenal-jejunal junction.
- It is very rare for bleeding entering the gut distal to this point to return to the stomach.
The colour and volume of the vomitus is an indicator to how long the blood has been in the stomach.
- Dark blood or ‘coffee grounds’ suggests a smaller bleed which has been altered by contact with gastric acid.
- A large volume of bright red blood is suggestive of a rapid and sizeable haemorrhage.
how may patients present
Symptoms
- Abdominal pain – may be epigastric or diffuse
- Haematemesis – vomiting of bright red blood
- Coffee-ground vomit – vomiting of black material (blood altered by gastric acid)
- Melaena – black tarry stools (digested blood)
- Haematochezia – passage of fresh blood per rectum (can occur in profuse upper gastrointestinal haemorrhage)
- Pre-syncope/syncope – due to hypovolaemia and cerebral hypoperfusion
Signs
- Tachycardia
- Hypotension
- Tender abdomen
- Malaena on rectal examinaton
- The extent to which these will occur will depend upon the source.
- Mortality is higher in patients presenting with haematemesis than malaena alone.
3 main qs that should be in ur head when u come across upper gi bleed
Upper gastrointestinal bleeding may be considered in terms of:
- frequency of different causes: common, uncommon or rare
- sites of bleed: a surgical approach
- are any tissues actively bleeding
- emergencies-
- oesophageal varices
- gastric ulceration [60% of haematemesis cases]
- non emergencies-
- mallory weiss tear
- oesophagitis
- gastritis
- gastric malignancy
- meckel’s diverticulum
- vasc malformation eg. dieulafoy lesion
- emergencies-
haematemesis aetiology by frquency
Most commonly an upper gastrointestinal bleed is a result of:
- chronic peptic ulcer:
- duodenal ulcer (40%)
- gastric ulcer (20%)
- acute peptic ulcer (30%)
Less commonly:
- Mallory-Weiss syndrome
- gastric erosions
Rarely, the following causes will be found:
- oesophageal / gastric varices, e.g. in portal hypertension
- erosive oesophagitis, e.g. due to a hiatus hernia
- duodenitis
- gastric carcinoma
- hereditary haemorrhagic telangiectasia
- pancreatitis
- haemobilia, i.e. bleeding from the gall bladder or biliary tree
Considering upper gastrointestinal bleeding in terms of the site of the bleed:
pharynx:
- vomiting of swallowed blood from a nasal bleed
oesophagus:
Oesophagitis
Small volume of fresh blood, often streaking vomit. Malaena rare. Often ceases spontaneously. Usually history of antecedent GORD type symptoms.
Cancer
Usually small volume of blood, except as pre terminal event with erosion of major vessels. Often associated symptoms of dysphagia and constitutional symptoms such as weight loss. May be recurrent until malignancy managed.
Mallory Weiss Tear
Typically brisk small to moderate volume of bright red blood following bout of repeated vomiting. Malaena rare. Usually ceases spontaneously.
Varices
Usually large volume of fresh blood. Swallowed blood may cause malaena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed.
stomach:
Gastric cancer
May be frank haematemesis or altered blood mixed with vomit. Usually prodromal features of dyspepsia and may have constitutional symptoms. Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage.
Dieulafoy Lesion
Often no prodromal features prior to haematemesis and malaena, but this arteriovenous malformation may produce quite considerable haemorrhage and may be difficult to detect endoscopically
Diffuse erosive gastritis
Usually haematemesis and epigastric discomfort. Usually there is an underlying cause such as recent NSAID usage. Large volume haemorrhage may occur with considerable haemodynamic compromise
Gastric ulcer
Small low volume bleeds more common so would tend to present as iron deficiency anaemia. Erosion into a significant vessel may produce considerable haemorrhage and haematemesis.
duodenum:
- duodenal ulcer
- Most common cause of major haemorrhage is a posteriorly sited duodenal ulcer.
- However, ulcers at any site in the duodenum may present with haematemesis, malaena and epigastric discomfort.
- The pain of duodenal ulcer is slightly different to that of gastric ulcers and often occurs several hours after eating.
- Peri ampullary tumours may bleed but these are rare.
- In patients with previous abdominal aortic aneurysm surgery aorto-enteric fistulation remains a rare but important cause of major haemorrhage associated with high mortality.
- duodenitis
upper gi hx
- timing, freq, volum of bleed
- hx od sypepsia, dysphagia, odynophagia
- pmh, smoking, alcohol status
- steroid/nsaid use/ anticoag/bisphosphonate use
o/e:
- epigasrtric tenderness
- evidence of varices/liver stigmata
- point of bleeding in mouth/nose
upper gi ix
- abg - esp lactate: tissue hypoperfusion
- routine bloods after inserting cannula:
- Full blood count (FBC) – Hb may be decreased in the context of acute blood loss
- Coagulation studies – deranged in liver disease and may indicate the need to replace clotting factors
- Group and Crossmatch – requesting blood early is essential – in emergency use O negative blood
- U&Es – raised urea occurs in UGIB due to digestion and absorption of blood proteins
- LFTs – if liver disease is suspected then this can assist in confirming the diagnosis
- best ix: OGD!
- do w/i 12-24 hrs in most caes or asap if patient is unstable - erect cxr
- if suspect perforated peptic ulcer- may see pneumoperitoneum [air beneath diaphragm] - ct abdo with iv contrast
- assesses active bleeding if endoscopy unremarkable/pt too ill for invasive ix
acute upper gi bleed mx
Risk assessment
- use the Blatchford score at first assessment, and
- the full Rockall score after endoscopy
Patients with a Blatchford score of 0 may be considered for early discharge
Resuscitation
- ABC, wide-bore intravenous access * 2
- platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre
- fresh frozen plasma to patients who have either a fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal
- prothrombin complex concentrate to patients who are taking warfarin and actively bleeding
Endoscopy
- should be offered immediately after resuscitation in patients with a severe bleed
- all patients should have endoscopy within 24 hours
- Identifiable bleeding points should receive combination therapy of injection of adrenaline and either a thermal or mechanical treatment.
- All who have received intervention should receive a continuous infusion of a proton pump inhibitor (IV omeprazole for 72 hours) to reduce the re-bleeding rate.
Management of non-variceal bleeding
- NICE do not recommend the use of proton pump inhibitors (PPIs) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding although PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy
- if further bleeding then options include repeat endoscopy, interventional radiology and surgery
Management of variceal bleeding
- terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)
- band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices
- transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures
blatchford score
The need for admission and timing of endoscopic intervention may be predicted by using the Blatchford score.
This considers a patients Hb, serum urea, pulse rate and blood pressure.
Assesses probability for intervention (Blood Transfusion, endoscopy, surgery)
Score 0
- Low risk for intervention
- Reasonable to manage as outpatient
Score >0
- Increased risk for intervention and inpatient management is recommended
- However most cases <5 respond without signficant intervention
Score >5
- High risk for intervention
- require admission and endoscopy.
rockall score
Following endoscopy it is important to calculate the Rockall score for patients to determine their risk of rebleeding and mortality
A score of 3 or less is associated with a rebleeding rate of 4% and a very low risk of mortality and identifies a group of patients suitable for early discharge.
terlipressin/octreotide MOA
somatostatin analogues
decrease splanchic blood flow = decreases bleeding
when might surgery be done
Patients with diffuse erosive gastritis who cannot be managed endoscopically and continue to bleed may require gastrectomy
Bleeding ulcers that cannot be controlled endoscopically may require laparotomy and ulcer underruning
Indications for surgery
- Patients > 60 years
- Continued bleeding despite endoscopic intervention
- Recurrent bleeding
- Known cardiovascular disease with poor response to hypotension
Surgery
Duodenal ulcer
- Laparotomy, duodenotomy and under running of the ulcer.
- If bleeding is brisk then the ulcer is almost always posteriorly sited and will have invaded the gastroduodenal artery.
- Large bites using 0 Vicryl are taken above and below the ulcer base to occlude the vessel.
- The duodenotomy should be longitudinal but closed transversely to avoid stenosis.
For gastric ulcer
- Under-running of the bleeding site
- Partial gastrectomy-antral ulcer
- Partial gastrectomy or under running the ulcer- lesser curve ulcer (involving left gastric artery)
- Total gastrectomy if bleeding persists
how ppi’s are helpful in haematemesis rx!!
A gastric acidic environment of less than pH 5.4 alters coagulation function and activates pepsin to disaggregate platelet plugs.
Gastric acid is secreted by H+, K+-ATPase, naming the proton pump
Proton pump inhibitors (PPI) are a group of drugs which profoundly reduce acid secretion in the stomach. They irreversibly blocking the hydrogen/potassium adenosine triphosphatase enzyme system (the H+/K+ ATPase) of the gastric parietal cell
Examples include omeprazole and lansoprazole.
what is the AIMS65 scoring system
risk score for in hosp mortality from upper gi bleeding
