What is haematemesis?
What is malaena?
What are causes of maleana?
- Peptic ulcer disease
- Oesophageal varices
- Mallory–Weiss tear
What is the mechanism behind malaena?
Bleeding from any cause in the upper gastrointestinal tract can result in melaena. It is often said that bleeding must begin above the ligament of Treitz; however, this is not always the case.
The black, foul-smelling nature of the stool is due to the oxidation of iron from the haemoglobin, as it passes through the gastrointestinal tract.
What are common causes of upper GI bleeding?
- Peptic ulcers
- Mallory-Weiss tears
- Oesophageal varcies
- Gastritis/Gastric ulcers
- No Obvious cause
What drugs can cause upper GI bleeding?
What would you want to ask someone who was presenting with features of an upper GI bleed?
- Past GI bleeds
- Dyspespsia/known ulcers
- Known liver disease/oesophageal varices
- Weight loss
- Drugs and alcohol use
- Serious comorbidities - CVS, Resp, hepatic/renal, malignancy
What symptoms can occur in an acute upper GI bleed?
- Dizziness/Psotural Syncope
- Abdo pain
What signs might indicate someone is having an upper GI bleed?
- Signs of liver disease - telangiectasia, purpura, jaundice
- Signs of shock
- Hypotension (SBP <100mmHg)/Postural drop >20 mmHg
- Decreased JVP
- Decreased Urine output
How would you manage someone having an acute GI bleed who was shocked?
- Protect airway, give O2
- Circulation assessment + 2 large bore cannulae
- Rapid crystalloid infusion - Consider Blood transfusion if severe shock
- Correct clotting abnormalities
- Catheterise and monitor urine output
- 15 minute obervations
- Urgent endoscopy
- Consider surgery if bleeding persists
What bloods would you perform if someone presented in shock from an upper GI bleed?
Why would you consider putting in a CVP monitor in someone recieving blood transfusion for an acute GI bleed?
To assess transfusion adequacy and overload on the heart
When would you consider transfusion in someone with an upper GI bleed?
- Haemoglobin <80 g/L
- Patients with active bleeding
What drugs would you want to check for (and stop) in someone having an acute GI bleed?
What can be used to control uncontrolled variceal bleeding?
- Trans-jugular intrahepatic porto-systemic shunt (TIPS)
- Balloon tamponade - Sengstaken-Blakemore tube - compresses the varcies
What can cause Mallory-Weiss tears?
Sudden inicrease in intra-abdominal pressure
- Heavy coughing
- Heavy wretching/dry heaves
How would you manage a varcieal bleed?
- IV Terlipressin
- Broad-spectrum IV antibiotics
- Endotherapy - variceal ligation/Sclerotherapy
- Correct any coagulopathies
How would you manage bleeding ulcers?
- Haemostatic therapy - 2 out of 3/3 out of 3 of clips, cautery or adrenaline
- Post endoscopic PPI's
- Consider H. Pylori erdication therapy
- Discontinue causative therapies - NSAIDs, aspirin
What scoring systems are used to stratify Upper GI bleeds?
- Glasgow-Blatchford bleeding score - initial risk assessment of acute upper GI bleed
- Rockall score - identify patients at risk of complications following acute upper GI bleed
What is coffee-ground vomit suggestive of?
Slow, intermittent bleed
What is regarded as the point which distinguishes an upper GI bleed from a lower GI bleed?
Ligament of trietz
Which does coffee-ground vomit indicate as a cause of haematemesis; peptic ulcers or variceal bleeding?
What would brisk haematemesis be indicative of as a cause?
- Variceal bleeding
- Actively bleeding gastro-duodenal ulcer
What is haematochezia most commonly associated with; UGIB or LGIB?
LGIB - but can be upper in severe UGIB
Why might urea be raised in an upper GI bleed?
As blood passes through the small bowel and is partially digested, it can result in an elevated urea and urea/Cr ratio - equivalent to a large protein meal
What proportion of oesophageal varices will rebleed in a year?