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Mrs Brown, a 70 year old lady, arrives in your A&E by ambulance one Saturday night along with her son. He tells you she vomited blood earlier that evening and then collapsed. You are the F2 on call, identify the cause of her haematemesis and form a management plan.

Mrs Brown is currently lying on a bed in A&E, alert and orientated.

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 questions might be useful to elicit further details surrounding the presenting complaint?

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What did the blood look like?

“Fresh red blood doctor, and a lot of it! I was throwing up for ages, it felt like bucketfuls!”

 

Is this the first time you have vomited blood?

“Yes, never had anything like this before! It’s terrifying!”

 

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

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

 

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

“Nothing… except 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 any alcohol? Have you ever drunk in the past?

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

 

Do you take any regular medicines?

“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!”

What else might be useful to gain further details about the haematemesis and collapse?

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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 was she orientated? 

“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 lot of blood on the floor and even more in the toilet. I’d say at least 300-500mls, but it’s hard to say”

Examination

What approach would you apply in the initial assessment of Mrs Brown?

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ABCDE approach is the most appropriate in the acute assessment phase, to ensure you methodically identify any life threatening features and correct them as you go.

A – Patent

 

B – Good expansion, equal air entry bilaterally, chest clear. Resp rate 10, sats 92%

 

C – Mrs Brown looks pale, and feels cool and clammy. Her capillary refill time is 3 seconds. Heart rate is 100, blood pressure is 100/70. Her ECG shows sinus tachycardia.

 

D – BM is 6.0. Pupils are equal and reactive to light. She is alert.

 

E – General examination shows no stigmata of chronic liver disease. There is some mild epigastric tenderness with no guarding or rebound.

What other clinical examination would be essential to include during this assessment?

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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.

After performing your initial assessment, who should you immediately involve?

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The first person to involve would be a senior in A&E, either a senior registrar or consultant. They would then liaise with the gastroenterologist if appropriate. If the patient was deteriorating other specialities such as anaesthetics or the surgeons may need to be involved. The key message here is recognising the patient has had a significant bleed and the potential for rapid deterioration, so seniors involvement is essential.

What might your initial management include whilst performing the ABCDE assessment, given the findings above?

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Airway / Breathing

As part of your ABCDE assessment, you’d give oxygen as her O2 sats are on the lower side of normal. 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 O2 sats are only slightly reduced would be to use nasal cannulae.

 

Circulation

This is the main problem in this scenario as she is haemodynamically unstable. She therefore requires urgent resuscitation,  so you need IV access (ideally 2 large wide-bore cannulae). From these take bloods including FBC, U&Es, LFTs, clotting. Also group and crossmatch blood.

Give IV fluids (crystalloids) while waiting for blood to be cross-matched to increase circulating volume. If there is ongoing significant blood loss and haemodynamic instability, emergency use of O-negative blood may be required, this would be a consultant / registrar led decision.

Given the haemodynamic compromise and need for fluid resuscitation, catheterisation can be useful to closely monitor urine output, which provides a proxy measure of end organ perfusion.

A blood transfusion to replace the loss may be required, the amount of replacement would depend on the volume of blood lost and the haemoglobin level.

Correction of any identified clotting abnormalities may be required with Vitamin K, FFP or platelets. Haematology may need to be involved with this aspect of management.

Investigations

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

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Full blood count:

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

Biochemistry:

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

Coagulation – normal

Differential diagnosis

What is the differential diagnosis?

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The history and examination findings are suggestive of an upper gastrointestinal bleed. 

Causes of upper gastrointestinal bleeding include:

  • Peptic ulcer – may be secondary to H pylori or drugs such as NSAIDS
  • Severe oesophagitis / 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
  • Other rare causes. ¹

Risk stratification 

What is her Blatchford score?

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

 

Admission risk marker Score component value
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 (mm Hg)
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

Answer 

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Mrs Brown scores 7 due to her blood results, observations and presentation with syncope.

She will therefore benefit from being treated in hospital.

Further management

Mrs Brown has been resuscitated and has had a blood transfusion. Her observations are trending towards normal. You keep her under monitoring with observations every 15 minutes. After a few hours she becomes clinically stable.

What would the next steps of management be?

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Arrange endoscopy to occur within 24 hours of her admission.

NICE guidelines recommend offering endoscopy to unstable patients with severe acute upper GI bleeding immediately after resuscitation. All other patients with upper GI bleeding should be offered it 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. 

What is her Rockall score?

The Rockall score¹ gives estimates the risk of rebleeding and gives an ideal of mortality. 4/1

A score of <3 is a good prognosis while >8 suggests 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 on endoscopy Mallory Weiss/normal All other diagnoses Malignancy
Endoscopy findings No bleeding visible/spot Visible blood/ clot/spurting vessel

Answer

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

What management strategies should be used to reduce the risk of recurrence?

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Proton pump inhibitor therapy

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

 

H.pylori screening and eradication

She should be offered H. pylori screening, and eradication if positive. 3, 6

This is often done as part of the 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 catalyzes the conversion of urea to ammonia and carbon dioxide.

 

Review of medications

She should discontinue her NSAID as a peptic ulcer has been diagnosed and she should be offered gastric protection in the form of PPIs 6. Whilst as an inpatient you should discuss alternative options managing her back pain avoiding NSAIDS. In addition you should assess her back pain with appropriate clinical examination and further investigations.

How would you pick up on re-bleeding?

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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 (see Rockall Score).

 

To pick up early on possible rebleeding you should:¹

  • Check observations hourly
  • Re-examine after 4 hours
  • Transfuse to keep blood >100g/L
  • Daily bloods- FBC, U&E, LFT
  • Keep nil by mouth for 24h and slowly reintroduce a normal diet

What would be the clinical signs suggestive of rebleeding?

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The signs of rebleeding are: ¹

  • Rising heart rate
  • Decreasing hourly urine output
  • Haematemesis/melaena
  • Fall in BP (late sign, serious) and falling conscious level

Take home points

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  • 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. Patients with a score of 0 can be treated in the community
  • Use the full Rockall score after endoscopy
  • Patients who rebleed have a high mortality rate
  • Perform H Pylori testing and treatment for patients with peptic ulcer bleeding, and discontinue NSAIDs where possible

References

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  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 need for treatment for upper-gastrointestinal haemorrhage. Lancet (London, England) [Internet]. 2000 Oct 14;356(9238):1318–21. Available from: http://www.sciencedirect.com/science/article/pii/S0140673600028166
  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: http://www.nice.org.uk/guidance/cg141/chapter/1-recommendations
  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: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1727413&tool=pmcentrez&rendertype=abstract
  5. Committee JF. British National Formulary (online) [Internet]. London: BMJ Group and Pharmaceutical Press. Available from: http://www.medicinescomplete.com
  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: https://www.nice.org.uk/guidance/cg184/chapter/1-recommendations

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