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Haematemesis and melaena

Acute severe upper gastrointestinal haemorrhage is an important medical emergency.

A sudden loss of 20% or more circulatory blood volume usually produces signs of shock, such as tachycardia, hypotension, faintness and sweating.

Haematemesis: diagnostic strategy model

Probability diagnosis

• Chronic peptic ulcer (stomach and duodenum) 50%

• Acute gastric ulcers/erosions 20%

• Oesophagitis (incl. GORD)

• Mallory–Weiss (emetogenic) syndrome

• Drugs: aspirin, NSAIDs, anticoagulants, clopidogrel

Serious disorders not to be missed

• Vascular:

  • oesophageal varices

  • blood dyscrasias

  • vascular malformation/angiodysplasia

  • hereditary coagulopathy

• Cancer:

  • gastric or oesophageal

• Other:

• chronic liver disease

Pitfalls (often missed)

• Stomach ulcer

• Swallowed blood (e.g. epistaxis)

• Collagen diseases (e.g. scleroderma)

Rarities

• Ruptured oesophagus

• Hereditary haemorrhagic telangiectasia

Key history

• 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

Key examination

• Patient's general state including circulation, vital signs

• Abdominal examination and rectal examination

• Evidence of liver disease

Key investigations

• Upper GIT endoscopy diagnoses bleeding source in 80%

• FBE

• LFTs including γ GT

• Helicobacter pylori tests

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

Causes of upper GI bleeding

The major cause of bleeding is chronic peptic ulceration of the duodenum and stomach, which accounts for approx. half of all cases. The other major cause is acute gastric ulcers and erosions, which account for at least 20% of cases. Aspirin and NSAIDs are responsible for many of these bleeds. Causes are illustrated in Fig. H1.

Investigations

Investigations to determine the source of the bleeding should be carried out in a specialist unit. Endoscopy will detect the cause of the bleeding in at least 80% of cases.

Management

The immediate objectives are:

1. restore an effective blood volume (if necessary)

2. establish a diagnosis to allow definitive treatment

All patients with a significant bleed should be admitted to hospital and referred to a specialist unit. Urgent resuscitation is required where there has been a large bleed and there are clinical signs of shock. Such patients require an intravenous line inserted and transfusion with blood cells or fresh frozen plasma (or both) commenced as soon as possible.

In many patients bleeding is insufficient to decompensate the circulatory system and they ...