7 Haematemesis

Definitions
GI bleeding is any blood loss from the GI tract (from the mouth to the anus), which may present with haematemesis, melaena, rectal bleeding or anaemia. Haematernesis is defined as vomiting blood and is usually caused by upper GI disease. Melaena is the passage PR of a black treacle-like stool that contains altered blood, usually as a result of proximal bowel bleeding.
KEY POINTS
• Haematemesis is usually caused by lesions proximal to the duodenojejunal junction.
• Melaena may be caused by lesions anywhere from oesophagus to
colon (upper Cl lesions can cause frank PR bleeding).
• Most tumours more commonly cause anaemia than frank haematemesis.
• In young adults, peptic ulcer disease (PUD), congenital lesions and
varices are common causes.
• In the elderly, tumours, PUD and angiodysplasia are common causes.
Important diagnostic features
Ocsophagus
• Reflux oesophagitis: small volumes, bright red, associated with regurgitation.
• Oesophageal carcinoma (rare): scanty, blood-stained debris, rarely significant volume, associated with weight loss, anergia, dysphagia.
• Bleeding varices: sudden onset, painless, large volumes, dark red blood, history of (alcoholic) liver disease, physical findings of portal hypertension.
• Trauma during vomiting (Mallory—Weiss syndrome): bright red bloody vomit usually preceded by several normal but forceful vomiting episodes.

Stomach
• Erosive gastritis: small volumes, bright red, may follow alcohol or NSAID intake/stress, history of dyspeptic symptoms.
• Gastric ulcer: often larger-sized bleed. painless, possible herald smaller bleeds, accompanied by altered blood (‘coffee
grounds’), history of PUD.
• Gastric cancer: rarely large bleed, anaemia commoner, associated weight loss, anorexia, dyspeptic symptoms.
• Gastric leiomyoma (rare): spontaneous-onset moderate-sized
bleed.
• Dieulafoy’s disease (rare): younger patients, spontaneous
large bleed, difficult to diagnose.
Duodenum
• Duodenal ulcer: past history of duodenal ulcer, melaena often
also prominent, symptoms of back pain, hunger pains, NSAID use.
• Aortoduodenal fistula (rare): usually infected graft post AAA
repair, massive haematemesis and PR bleed, usually fatal.

KEY INVESTIGATIONS
• FBC: carcinomas, reflux oesophagitis.
• LETs: liver disease (varices).
• Clotting: alcohol, bleeding diatheses.
• OCD: investigation of choice. High diagnostic accuracy, allows
therapeutic manoeuvres also (varices: injection; ulcers:
injection/cautery).
• Angiography: rare duodenal causes, obscure recurrent bleeds.
• Barium meal and follow through: useful for patients who are unfit for
OCD (respiratory disease) and ?proximal jejunal lesions.

MANAGEMENT
Minor bleed: Resusctaton Major bleed:
observation Continued resuscitation, urgent OCD
scheduled OCD _—
monitor haemoglobin and fluid balance. Peptic ulcer Varices Castritis
Endoscopic therapy Endoscopic therapy iv. PPI treatment
Re-bleed or high risk: surgery Sengstaken tube Early feeding
Surgery