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Student medical journal

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 and Nutrition.
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 Resuscitation
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 Tamponade
Initially effective in 85%, but re-bleeding occurs (12). Endoscopic treatment
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 Surgical
Decrease portal hypertension > 90 % effective.(15) without compromising liver function. References
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 ulcer. Gastroenterology 1991;100(1):33-37. 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.

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