Clinical notes Evidence based management of haematemesis DP Wickramasinghe, DN Samarasekara Department of Surgery, Faculty of Medicine, University of Colombo This article is based on the National guidelines
The patient should be assessed to estimate the
on the management of upper gastro intestinal
blood loss (table 1). If the patient is not in shock, a
bleeding, published by the Ministry of Healthcare
slow infusion of 0.9 % NaCl should be started to
Haematemesis (vomiting of fresh blood) is a
If the patient is in shock he should receive 8 – 10
feature of acute upper gastrointestinal bleeding
litres of oxygen/min via face mask and a rapid
(UGIB) and is the presenting feature in 30-40 % of
infusion of fluid with the aim of euvolaemic
patients with UGIB. The amount of blood loss can
resuscitation as guided by a urine output of 0.5 – 1
vary from a few millilitres to litres and the initial
ml/kg/hr. In most patients, 1 – 2 litres of
management depends on the volume lost, as well
crystalloids will correct the losses, but further
replacement should include plasma expanders as
this suggests that at least 20 % of blood volume
The management can be described in 3 steps.
2. Identification of the cause and the site
If the bleeding is extreme or if the haemoglobin is
less than 80 g/l, red cell concentrate should be
Omeprazole 80 mg should be given intra venous as
The airway must be protected and aspiration
a bolus and continued as 8 mg/hour over the next
prevented. A nasogastric tube can be used in a
conscious patient with copious vomiting but a
semiconscious or unconscious patient will need to
Identification of cause and site
be turned to the left lateral position, with an
A quick history and examination may be useful in
oropharyngeal airway or endotracheal intubation.
identification of the cause and the site i.e.
If facilities are available, the adequacy of
dyspepsia or NSAID use (peptic ulcers), episodes
respiration should be assessed continuously with
of vomiting prior to haematemesis (Mallory Weiss
pulse oximetry or with blood gas analysis.
syndrome), stigmata of chronic liver disease
Two 14 FG (orange) cannulae should be inserted
to both arms, and blood should be taken for full
blood count (to assess the haemoglobin level,
demonstrate the lesion as well as offer several
packed cell volume and platelets), PT / INR, cross
matching, blood urea, serum electrolytes and liver
function tests when suspecting hepatic pathology.
Management of Non-Variceal bleeding
The patient should be catheterized to measure the
Several endoscopic and pharmacological treatment
Table 1: Estimation of fluid and blood losses in shock Blood loss ( ml ) Blood loss ( % of total ) Pulse rate Blood pressure Respiratory Mental status replacement Table 2:Management options for gastric bleeding Treatment option Dose / Method Evidence base Endoscopic
Adrenaline 1:10,000 in normal No single solution is superior to saline, injected first to quadrants another (1) around the bleeder, then in to the vessel
20 – 30 Joules repeatedly applied No difference of re-bleeding, using heater probe or multipolar surgery
Clips applied to bleeding vessels, 2 studies have shown that its particularly
large superiority to injection or heater
probe, but 1 study showed higher failure rates (4).
Combination with injection is not better than injection alone or clips alone (4, 5) Pharmacological
for surgery when compared to H2 Antagonist or placebo (6).
Bleeding not responding to both the above
methods could be managed surgically. Gastric
octreotide and antifibrinolytics cannot be
ulcers could be treated by excision of the ulcer
or partial gastrectomy and duodenal ulcers
could be managed with distal gastrectomy
with Billroth I or II reconstruction, or under
Management of variceal bleeding
running the ulcer or the right gastro epiploic
endoscopic, tamponade or surgery (Table 3).
Table 3: Management of variceal bleeding Treatment option Dose / Method Evidence base Pharmacological
20 units in 200 ml normal Does not confer a survival saline bolus, followed by 0.2 benefit
Initially effective in 85%, but re-bleeding occurs (12).
Placement of a rubber band Lower mortality, re-bleeding, around the varix thereby perforation
Ethanolamine or Polidocanol injected either intra-variceal or para-variceal to create fibrosis in the mucosa.
Liquid tissue adhesive that is 90 % effective in the initial injected to the varix and bleed (14) rapidly polymerizes into a More
Decrease portal hypertension > 90 % effective.(15) without compromising liver function.
Rokkas T, et al. Eradication of Helicobacter pylori
Barkun A, Bardou M., Marshall JK. Consensus
reduces the possibility of rebleeding in peptic ulcer
recommendations for managing patients with nonvariceal
disease.Gastrointestinal Endoscopy 1995;41(1):1-4.
upper gastrointestinal bleeding. Annals of Internal
D'Amico G, Pagliaro L and Bosch J. The treatment of
portal hypertension: a meta-analytic review. Hepatology
Choudar, CP, Rajgopal C, Palmer KR. Comparison of
endoscopic injection therapy versus the heater probe in
major peptic ulcer haemorrhage. Gut 1992;33(9):1159-
10. Yavorski RT, et al. Analysis of 3,294 cases of upper
gastrointestinal bleeding in military medical facilities.
American Journal of Gastroenterology 1995;90(4):568-
Chung SC, et al. Injection or heat probe for bleeding
11. Bosch J, et al. Recombinant factor VIIa for upper
Chung IK, et al. Comparison of the hemostatic efficacy
gastrointestinal bleeding in patients with cirrhosis: a
of the endoscopic hemoclip method with hypertonic
saline-epinephrine injection and a combination of the
two for the management of bleeding peptic ulcers.
Gastrointestinal Endoscopy 1999;49(1):13-18.
12. Kupfer Y, Cappell MS, Tessler S. Acute gastrointestinal
bleeding in the intensive care unit. The intensivist's
Gevers AM, et al. A randomized trial comparing
perspective. Gastroenterology Clinics of North America
injection therapy with hemoclip and with injection
Gastrointestinal Endoscopy 2002;55(4):466-469.
13. Laine L, Cook D. Endoscopic ligation compared with
sclerotherapy for treatment of esophageal variceal
Lin HJ, et al. A prospective randomized comparative
bleeding. A meta-analysis. Annals of Internal Medicine
trial showing that omeprazole prevents rebleeding in
patients with bleeding peptic ulcer after successful
endoscopic therapy.Annals of Internal Medicine
14. D'Imperio N, et al. Evaluation of undiluted N-butyl-2-
cyanoacrylate in the endoscopic treatment of upper
gastrointestinal tract varices.Endoscopy 1996;28(2):239-
Graham DY, et al. Treatment of Helicobacter pylori
reduces the rate of rebleeding in peptic ulcer disease.
15. Corson J, Williamson R. Surgery. Elsevier Inc.;2001.
CURRICU LUM VITAE GREGORY M. KOCHAK , Ph.D. Affiliation: R&D Services, LLC, 663 N. 132nd Street, Suite 126, Omaha, NE 68154 SUMMARY OF SELECTED ACCOMPLISHMENTS • 18 Years experience in the pharmaceutical industry including senior management; 8 years in academia. Assembled and managed a multi-disciplinary department at an international pharmaceutical company. Assembled the
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