Haematemesis

Haematemesis is simply defined as “vomiting blood”. It is caused by bleeding from part of the upper portion of the gastrointestinal tract.

It has a wide range of possible causes, depending on the site of blood loss and the tissue that is actively bleeding. Indeed, patients with haematemesis can present in a number of clinical states.

In this article, we shall look at the causes, investigations and management of haematemesis.


Aetiology

Emergencies

Figure 1 – The portal venous system

Oesophageal Varices

Oesophageal varices refer to dilations of the porto-systemic venous anastomoses in the oesophagus. These dilated veins are swollen, thin-walled and hence prone to rupture, with the potential to cause a catastrophic haemorrhage (Fig 2A).

The most common underlying cause for oesophageal varices is portal hypertension resulting from alcoholic liver disease.  Any haematemesis in a patient with known history of alcohol abuse should be investigated with an urgent OGD.

Gastric Ulceration

Gastric ulceration is responsible for about 60% of haematemesis cases. Ulceration can result in erosion into the blood vessels supplying the upper GI tract (most commonly on the lesser curve of the stomach (20%) or posterior duodenum (40%)) and can result in significant haemorrhage.

Patients may present with known active ulcer disease / H. Pylori positive, a history of NSAID or steroid use, or previous epigastric symptoms suggesting peptic ulceration, all of which may aid your initial assessment and diagnosis.

Non-Emergencies

Mallory-Weiss Tear

A Mallory-Weiss tear is a relatively common phenomenon, typified by episodes of severe or recurrent vomiting, then followed by minor haematemesis. Such forceful vomiting causes a tear in the epithelial lining of the oesophagus, resulting in a small bleed.

Most cases are benign and will resolve spontaneously, therefore providing the patient reassurance and monitoring is usually all that is required. Any prolonged or worsening haematemesis warrants investigation with an OGD.

Oesophagitis

Oesophagitis is a condition that describes inflammation of the intraluminal epithelial layer of the oesophagus, most often due to either gastric acid reflux (GORD) or less commonly from infections (typically Candida Albicans, Fig 2B), medication (such as bisphosphonates), radiotherapy, ingestions of toxic substances, or Crohn’s disease.

Other Causes

Other causes of haematemesis that may not require such immediate resuscitation and intervention include gastritis, gastric malignancy, Meckel’s diverticulum, or vascular malformations (e.g. Dieulafoy lesion)

Fig 1 - Causes of haematemesis; (a) Oesophageal varices and (b) Oesophageal candidiasis

Figure 2 – Causes of haematemesis; (a) Oesophageal varices and (b) Oesophageal candidiasis


Clinical Features

The key facts to ascertain from a history of haematemesis are:

  • Timing, frequency, and the volume of bleeding
  • History of dyspepsia, dysphagia, or odynophagia
  • Past medical history and smoking and alcohol status
  • Use of steroids, NSAIDs, anticoagulants, or bisphosphonates

On examination, it is important to assess specifically for epigastric tenderness or peritonism, as well as features suggestive of a potential underlying cause, such as evidence of varices or liver stigmata


Investigations

Figure 3 – An erect chest radiograph, showing free air under the right diaphragm (pneumoperitoneum)

Following your initial assess, most patients will warrant routine bloods (FBC, U&Es, LFTs, and clotting) and a VBG to be taken

  • Any acute bleed may not initially show an anaemia in the FBC, whereas LFTs may reveal underlying liver damage as a potential cause.
  • All patients with haematemesis should have a Group and Save; those with significant haematemesis (especially suspected variceal bleed) should have at least 4 units of blood cross-matched.

The definitive investigation in most cases of haematemesis is via an oesophagogastroduodenoscopy (OGD), which also forms part of the management in cases of ongoing unstable bleeding. This should be performed within 12hrs in most cases of acute haematemesis or as soon as possible if the patient is unstable.

An erect CXR (Fig. 3) may also be required if a perforated peptic ulcer is suspected as the underlying cause. In such a case, air may be visible underneath the diaphragm (pneumoperitoneum).

 

Glasgow-Blatchford Bleeding Score

The Glasgow-Blatchford bleeding score (GBS) is a scoring system used to risk stratify patients admitted with an upper GI bleed, based purely on clinical and biochemical parameters. This allows for appropriate management of further investigations, especially as the score can be calculated prior to any OGD.

The score is determined by:

  1 2 3 4 5 6
Urea (mmol/L) 6.5-8.0 8.0-10.0 10.0-25.0 >25
Hb (g/L) 12.0-12.9 10.0-11.9 <10.0
Systolic BP 100-109 90-99 <90
Pulse (bpm) >100
Melena Present
Syncope Present
Known Hepatic Failure Present
Cardiac Failure Present

 

Interpretation will vary across endoscopy departments, but scores ≥6 have been associated with a >50% risk of needing an intervention. Other risk scores are used in the clinical setting, such as the AIMS65 Score (risk score for in-hospital mortality from upper GI bleeding) or Rockall Score (severity score for GI bleeding post-endoscopy)

CT abdomen with IV contrast (triple phase) can be useful in assessing any active bleeding in an unstable patient*, especially if endoscopy is unremarkable or the patient is too unwell to undergo invasive investigation

*RBC Scintigraphy is a more sensitive test that can be used to identify active bleeding, however is currently only used routinely in select centres


Management

Patients with haematemesis can be extremely unstable.  The first step in their management is a rapid ABCDE assessment, to insert two large bore IV cannulas, start IV fluid resuscitation if needed and send blood for group & save / X-match.

Most cases will warrant an OGD, from which a range of therapeutic options are available depending on the underlying causes suspected or confirmed:

  • Peptic ulcer disease – requires injections of adrenaline and cauterisation of the bleeding. High dose intravenous PPI therapy should be administered (e.g. IV 40mg omeprazole) to reduce acid secretion +/- H. Pylori eradication therapy if necessary
  • Oesophageal varices – management should be swift and performed at the same time as active resuscitation, including the use of blood products
    • Endoscopic banding (Fig. 4) is the most definitive method of management* however can be technically difficult
      • Prophylactic antibiotic therapy should be initiated
    • Somatostatin analogues (e.g. octreotide) or vasopressors (e.g. terlipressin) should also be started, acting to reduce splanchnic blood flow and hence reduce bleeding
    • Long term management warrants repeat banding of the varices and long-term beta-blocker therapy

*Sengstaken-Blakemore tube can be used in severe cases. It is inserted to the level of the varices and inflated to compress the bleeding

Fig 2 - Banding of oesophageal varices.

Figure 4 – Banding of oesophageal varices

An actively bleeding patient can also be treated with angio-embolisation, in which the bleeding vessel is embolised. This is most commonly the gastro-duodenal artery which is eroded into by an ulcer at the back of the first part of the duodenum.

Key Points

  • Regardless of the underlying cause, adequate initial resuscitation should always be priority
  • Most cases of haematemesis should be investigated with an OGD
  • Various scoring systems are available to allow for the risk stratify of patients admitted with an upper GI bleed

Quiz

Question 1 / 4
Which of the following is the correct description of Mallory-Weiss syndrome?

Quiz

Question 2 / 4
Which x-ray sign may indicate a perforated gastric ulcer?

Quiz

Question 3 / 4
Which of the following is NOT a part of the Rockall Risk Score?

Quiz

Question 4 / 4
Which of the following is an endoscopic therapy used to treat oesophageal varices?

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