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Probability diagnosis

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Chronic peptic ulcer (stomach and duodenum) 50%

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Acute gastric ulcers/erosions 20%

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Oesophagitis (incl. GORD)

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Mallory--Weiss (emetogenic) syndrome

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Drugs: aspirin, NSAIDs, anticoagulants, clopidogrel, NOACs

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Serious disorders not to be missed

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Vascular:

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  • oesophageal varices

  • blood dyscrasias, e.g. aplastic anaemia

  • vascular malformation/angiodysplasia

  • hereditary coagulopathy

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Cancer:

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  • gastric or oesophageal

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Other:

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  • chronic liver disease

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Pitfalls (often missed)

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Stomach ulcer

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Swallowed blood (e.g. epistaxis)

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Collagen diseases (e.g. scleroderma)

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Rarities:

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  • ruptured oesophagus

  • hereditary haemorrhagic telangiectasia

  • scurvy

  • ingested poisons (e.g. acid, alkali, arsenic)

  • gastric antral vascular ectasia

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Key history

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  • Nature of vomitus from fresh blood to ‘coffee grounds’

  • Is bleeding arising from the mouth, nose or pharynx?

  • Indigestion, heartburn or stomach pains

  • Associated symptoms (e.g. weight loss, jaundice)

  • Any bleeding problems

  • Drug history including alcohol, NSAIDs, antiplatelet agents, warfarin, steroids

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Key examination

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  • Patient’s general state including circulation, vital signs

  • Abdominal examination and rectal examination

  • Evidence of liver disease

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Key investigations

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  • Upper GIT endoscopy diagnoses bleeding source in 80%

  • FBE

  • LFTs including © GT

  • Helicobacter pylori tests

  • Imaging (e.g. plain erect X-ray, as indicated)

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Diagnostic tips

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  • Melaena occurs in 50% of cases of haematemesis.

  • Oesophageal bleeding tends to give vomiting fresh blood.

  • ‘Coffee grounds’ vomitus indicates contact with gastric acid.

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