Haematemesis

Question 1

What is the sign for pneumoperitoneum on a cxr?

Answer 1

Cupola sign = cup like dome (architectural etymology)

Question 2

Haematemesis vs haematochezia vs melena

Answer 2

Haematemesis = vomiting blood 
Haematochezia = fresh blood per anus 
Melena = dark stool (blood is mixed)

Question 3

Questions to ask about PC

Answer 3

How much blood was vomited?
Character of blood (colour)
Any blood in stool, if so what colour?
Did forceful coughing trigger it?
Any lethargy/ankle swelling/easy bruising/distended abdomen?
Recent weight loss?
Problems swallowing?
Epigastric pain?

Question 4

What would a coughing trigger suggest?

Answer 4

Malory-weiss tear or boehaave’s perforation

Question 5

What is a malory weiss tear?

Answer 5

A lesion/tear in the lining of the oesophagus, resulting in bleeding

Question 6

What might be the character of epigastric pain that suggests gastric carcinoma?

Answer 6

Gnawing/achey

Question 7

What might be the character of epigastric pain that suggests GORD

Answer 7

Episodic dyspepsia

Question 8

PMH key questions/conditions that might be relevant

Answer 8

GORD
Peptic ulcer 
Cirrhosis 
Aortic graft 
Helicobacter pylori 
Hx of cancer 
Bleeding tendency/clotting issues

Question 9

Why is GORD relevant?

Answer 9

Chronic GORD -> oesophagitis -> Barret’s oesophagus -> adenocarcinoma

Question 10

Histology of Barret’s oesophagus

Answer 10

Metaplastic change of oesophageal epithelium from stratified squamous to simple columnar, resembling the intestine’s goblet cells

Question 11

What does metaplastic change mean?

Answer 11

Reversible change

Question 12

Drugs that might be relevant and why

Answer 12

Beta blockers - might mask signs of shock and prevent tachycardia in a hypovolemic patient
Methotrexate - liver toxicity
NSAIDs - gastric irritation

Question 13

Name some drugs that can lead to peptic ulcer disease

Answer 13

Bisphosphonates 
Steroids
Clopidogrel 
Aspirin 
NSAIDS

Question 14

CAGE questions

Answer 14

Have you ever thought about CUTTING down your drinking?
Anyone been ANNOYED at you for drinking?
Ever felt GUILTY for drinking?
Ever opened your EYES in the morning and felt like you needed a drink to get over a hangover? (eye-opener)

Question 15

Dfx

Answer 15

Peptic ulcer
Oesophageal varices
Gastric/oesophageal cancer 
Angiodysplasia 
Mallory-Weiss tear
Gastrointestinal stromal tumour

Question 16

What is angiodysplasia? How do you differentiate this from everything else?

Answer 16

Abnormal formation of the blood vessels in the gut - not painful

Question 17

How bad is the haematemesis in oesophagitis/mallory weiss?

Answer 17

Oesophagitis and Mallory-Weiss tears are unlikely to result in significant haematemesis

Question 18

Three key investigations

Answer 18

LFT
Coagulation studies
Blood glucose

Question 19

Immediate management of vomiting

Answer 19

IV vasopressin analogue (terlipressin)
IV antibiotics
Refer to oncall endoscopy
Fluid resus with blood transfusion

Question 20

Two treatment options for oesophageal varices - explain what these are

Answer 20

Band ligation (literally putting a rubber band around the bulge so it doesn’t burst

Or sclerotherapy (injecting something that causes veins to shrink)

Question 21

What is used as the last resort?

Answer 21

Sengstaken-Blakemore tubes (balloon inflation)

Question 22

What else can be done? Explain this procedure

Answer 22

TIPPS (Transjugular, intrahepatic, portosystemic shunt)
Essentially creates a shunt between the portal vein and the jugular vein, bypassing the hepatic veins in order to relieve the portal pressure