A lady with haematemesis

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Mrs Brown, a 70-year-old lady, arrives in A&E by ambulance on a Saturday night along with her son. He tells you she vomited blood earlier that evening and then collapsed. Work through the case to reach a diagnosis and form a management plan.


History

Presenting complaint

“Well I’d not been feeling well all evening, then I was watching the TV when I started feeling sick and dizzy, so I went to the bathroom and threw up everywhere. When I saw that it was just blood I was terrified! I yelled for my son, got up to get to him but then I started feeling even dizzier and next thing I knew I was on the floor and my son was beside me calling an ambulance”

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.”


Examination

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).

Investigations

Mrs Brown’s blood results come back from the lab and are shown below.

Full blood count:

  • Hb – 100g/L
  • PLT – 400
  • WCC – 9.1

Biochemistry:

  • Urea – 7.5 mmol/L (2.5-6.7)
  • Otherwise unremarkable

Coagulation:

  • Normal

Differential diagnosis

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

Risk stratification 

The Blatchford score ² is a tool to suggest which patients with gastrointestinal bleeding can be managed out of hospital and which need to be treated in a hospital setting. Patients with a score of 0 can be treated out of hospital, as they generally have a very low associated mortality rate.

Blood urea (mmol/L)
≥6·5 <8·0 2
≥8·0 <10·0 3
≥10·0 <25·0 4
≥25 6
Haemoglobin (g/L) for men
≥120 <130 1
≥100 <120 3
<10·0 6
Haemoglobin (g/L) for women
≥100 <120 1
<100 6
Systolic blood pressure (mmHg)
100–109 1
90–99 2
<90 3
Other markers
Pulse ≥100 (per min) 1
Presentation with melaena 1
Presentation with syncope 2
Hepatic disease 2
Cardiac failure 2

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.


Further management

Mrs Brown has been resuscitated and has received a blood transfusion. Her vital signs are trending in the right direction. After a few hours, she is deemed clinically stable.

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

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


Rockall score

The Rockall score is useful when assessing the risk of re-bleeding and provides an estimate of associated mortality.4 A score of less than 3 is associated with a good prognosis, while a score of greater than 8 is associated with a high risk of death.

Score
Variable 0 1 2 3
Age <60 60-79 >80
Shocked? No SBP >100

Pulse >100

SBP<100

Pulse >100

Comorbidity None CCF, IHD, any other major Renal failure/ liver failure/malignancy
Diagnosis based on endoscopy findings Mallory Weiss/normal All other diagnoses Malignancy
Endoscopy findings No bleeding visible/spot Visible blood/ clot/spurting vessel

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)

Key points

  • Gastric ulcers secondary to NSAIDs are a common cause of haematemesis.
  • Perform immediate ABCDE management and resuscitation of unwell patients.
  • Use the Blatchford score on first assessment to help inform management decisions.
  • Use the Rockall score after endoscopy to assess the patient’s risk of re-bleeding.
  • Patients who re-bleed have a high mortality rate.
  • Perform H.Pylori screening and eradication for patients with peptic ulcer bleeding.

References

  1. Longmore M, Wilkinson I, Baldwin A, Wallin E. Oxford Handbook of Clinical Medicine (9 ed.). Oxford University Press. 2014. 923 p.
  2. Blatchford O, Murray WR, Blatchford M. A risk score to predict the need for treatment for upper gastrointestinal haemorrhage. Lancet (London, England) [Internet]. 2000 Oct 14;356(9238):1318–21. Available from: [LINK]
  3. National Institute for Clinical Excellence. Acute upper gastrointestinal bleeding in over 16s: management [Clinical Guideline 14] [Internet]. NICE guidelines. National Institute for Clinical Excellence; 2012. Available from: [LINK]
  4. Vreeburg EM, Terwee CB, Snel P, Rauws EA, Bartelsman JF, Meulen JH, et al. Validation of the Rockall risk scoring system in upper gastrointestinal bleeding. Gut [Internet]. 1999 Mar;44(3):331–5. Available from: [LINK]
  5. Committee JF. British National Formulary (online) [Internet]. London: BMJ Group and Pharmaceutical Press. Available from: [LINK]
  6. National Institute for Clinical Excellence. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. [Clinical Guideline 184] [Internet]. NICE Guidelines. National Institute for Clinical Excellence; 2014. Available from: [LINK]

 

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