A lady with haematemesis

What did the blood look like?

“Fresh red blood doctor, about a cupful.”

Is this the first time you have vomited blood?

“Yes, never had anything like this before.”

Any changes in your stool? Any blood in your stool?

“No, everything’s been fine from that end!”

Do you have any medical conditions? Particularly any stomach ulcers or liver problems?

“Nothing… except for this back pain, I’ve had for ages. I don’t know if I have anything else- I haven’t seen a doctor for 10 years.”

Do you drink alcohol or smoke? If so, how much?

“No, I never drink alcohol. I don’t smoke either.”

Do you take any regular medications?

“Nothing from the doctor’s, just painkillers.”

What type of pain killers?

“I’ve been taking ibuprofen for my back pain for the last 3 years. I never miss a dose!”

Collateral history

How did Mrs Brown look when you arrived?

“She was very pale when I got to her, she had some blood around her mouth.”

Was she conscious when you arrived?

“Not initially, she didn’t respond for the first 10-20 seconds.”

When she did regain consciousness and was she orientated when she became responsive? 

“She wasn’t confused, she was orientated, just upset and worried.”

What did the blood look like? Was it bright red or dark? How much blood did you see?

“There was blood around her mouth and it was red. I went into the bathroom and there was a blood on the floor and some more in the toilet. I’d say at least 1-2 cups worth, but it’s hard to say.”

ABCDE approach is the most appropriate in the acute assessment phase, to ensure you methodically identify any life-threatening features and stabilise the patient.

Airway:

• The airway is patent

Breathing:

• Normal chest expansion
• Chest clear on auscultation with equal air entry
• Respiratory rate 10
• SpO2 92% on air

Circulation:

• Mrs Brown looks pale and feels cool and clammy
• Her capillary refill time is 3 seconds
• Heart rate is 100 bpm
• Blood pressure is 100/70 mmHg
• ECG shows sinus tachycardia

Disability:

• BM is 6.0
• Pupils are equal and reactive to light
• She is alert

Exposure:

• No stigmata of chronic liver disease
• Mild epigastric tenderness with no guarding or rebound

Rectal (PR) examination should be carried out during the E part of the assessment to identify any melaena or haematochezia suggesting ongoing bleeding.

PR examination shows only soft brown stool with no evidence of bleeding.

The first person to involve would be a senior doctor in A&E (e.g. registrar or consultant). Typically the senior doctor would then liaise with the gastroenterologist on-call. If the patient was deteriorating other specialities such as anaesthetics or the surgeons may need to be involved. The most important thing is to recognise that the patient is likely to be experiencing a significant gastrointestinal haemorrhage and to involve senior doctors early.

Airway and Breathing

• Administer oxygen as SpO2 is slightly low
• If applying an oxygen mask, keep in mind if she has another episode of haematemesis you will need to take this off immediately, to reduce the chance of aspiration (a more sensible alternative given her oxygen saturations are only slightly reduced would be to use nasal cannulae).

Circulation

This patient is haemodynamically unstable and therefore requires several interventions including:

• Large-bore IV access (x2)
• Blood tests – FBC, U&Es, LFTs, clotting, group and crossmatch blood
• IV fluids (crystalloids)
• Blood transfusion – to replace blood lost due to haemorrhage
• Strict fluid balance (including catheterisation to measure urine output accurately)
• Correction of any identified clotting abnormalities may be required with vitamin K, FFP and platelets (haematology should be involved with this aspect of the patient’s management).

The history and clinical findings are suggestive of an upper gastrointestinal bleed (UGIB).

Underlying causes of UGIB include:

• Peptic/duodenal ulcer – may be secondary to H.Pylori or drugs such as NSAIDs
• Oesophageal erosions
• Mallory-Weiss tear – the history should include forceful retching preceding any bleeding
• Bleeding varices – as a result of portal hypertension (e.g. advanced liver cirrhosis)
• Malignancy – bleeding tumour or erosion of gastrointestinal vessels

Mrs Brown scores 7 based on her blood results, vital signs and clinical presentation involving syncope. The patient’s score suggests she would benefit from hospital-based management.

An endoscopy should be arranged to be performed within 24 hours of her admission.

NICE guidelines recommend offering endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation. All other patients with upper gastrointestinal bleeding should be offered endoscopy within 24 hours of admission. ³

Endoscopy findings

On endoscopy, there was a visible clot on the lesser curve of the stomach which was mechanically clipped along with adrenaline.

Other methods which can be used to stop the bleeding are thermal coagulation with adrenaline or fibrin/thrombin with adrenaline.³

Much to everyone’s relief, Mrs Brown recovers from this acute episode over the next couple of days.

Mrs Brown’s Rockall score is 5, which gives her a 10.8% risk of mortality.

Proton pump inhibitor (PPI) therapy

• Administer omeprazole 80mg as a bolus IV dose then prescribe a continuous IV omeprazole infusion at 8mg/hr for 72 hours.
• After 72 hours, switch to oral therapy which should continue long term. ⁵

H.Pylori screening and eradication

• The patient should be offered H.Pylori screening and eradication if positive. ^{3, 6}
• This is often performed at the same time as endoscopy and is known as the Campylobacter-like organism test (CLO). The basis of the test is the ability of H.Pylori to secrete the urease enzyme, which catalyses the conversion of urea to ammonia and carbon dioxide.

Medication review

• The patient should be told to discontinue her use of NSAIDs, given the diagnosis of a peptic ulcer. ⁶
• Whilst in hospital, an alternative pain management strategy should be implemented for her back pain (she may also need further investigation of this presenting complaint).

NICE guidelines suggest considering a repeat endoscopy, with treatment as appropriate, for all patients at high risk of re-bleeding, particularly if there is doubt about adequate haemostasis at the first endoscopy. ³ Rebleeding is a serious event with up to 40% mortality.

To clinically monitor for possible rebleeding you should do the following: ¹

• Check vital signs hourly
• Re-examine the patient after 4 hours
• Perform daily blood tests – FBC, U&Es, LFTs

Clinical signs associated with rebleeding include: ¹

• Tachycardia
• Reduced urine output
• New haematemesis and/or melaena
• Hypotension (late sign)