Haematemesis and melaena

Chapter 8 HAEMATEMESIS AND MELAENA




KEY POINTS



• Resuscitation should be instituted irrespective of the underlying cause of gastrointestinal bleeding.

• A multidisciplinary approach to management is key.

• Patients over 60 years of age and patients with comorbid conditions have a higher risk of mortality.

• Endoscopic examination should be made available to the patient within 24 hours or when the patient is stabilised.

• A combination of adrenaline injection with either thermal coagulation or haemoclips reduces the risk of recurrent bleeding.

• Proton pump inhibitors are recommended as an adjuvant to endoscopic therapy in peptic ulcer patients with a high risk of bleeding.

• Somatostatin or octreotide are effective therapy for acute variceal bleeding.

• Angiography may help identify bleeding from an unknown source.

• Indications for surgery include arterial bleeding that cannot be controlled by endoscopic haemostasis, and patients requiring massive transfusions.


INTRODUCTION


Acute gastrointestinal (GI) bleeding is one of the most common emergency conditions and is associated with significant morbidity and mortality. Haematemesis is the vomiting of fresh blood. Haematemesis indicates that bleeding originates from a site proximal to the ligament of Treitz. A history of fresh haematemesis usually implies a significant bleed. Vomiting altered blood that appears like coffee grounds arises from the breakdown of haemoglobin by gastric acid, and often indicates that active bleeding may have ceased. Melaena is the passage of black, tarry stool. It occurs when haemoglobin is converted to haematin by bacterial degradation. Ingestion of as little as 200 mL of blood can produce melaenic stool. Although melaena generally connotes bleeding proximal to the ligament of Treitz, bleeding from the small intestine or proximal colon may also cause melaena, especially when colonic transit is slow. Haematochezia is the passage of pure red blood or blood admixed with stool. It usually occurs as a result of bleeding in the lower GI tract. It can also be present in massive upper GI bleeding (in 10%–15% of cases).



RESUSCITATION


Irrespective of the underlying cause of GI bleeding, a patient should be resuscitated. Vital signs (blood pressure, pulse, oxygenation) should be carefully monitored. A large bore peripheral drip should be inserted for fluid replacement and, if the patient is in shock, a central line inserted. Blood transfusion should not be delayed if there is evidence of substantial volume loss. Patients with chronic liver diseases might also benefit from fresh frozen plasma and platelet transfusion. A patient with GI bleeding is best cared for by a joint team with gastroenterologists, GI surgeons and intervention radiologists. Patients with severe acute bleeding require admission to a high dependency or intensive care unit.



AETIOLOGY


The most common cause of upper GI bleeding is peptic ulcer. This is followed by mucosal erosions, Mallory-Weiss tear, oesophagitis and oesophageal/gastric varices. In the lower GI tract, the most common causes of bleeding are diverticular disease, vascular malformation, inflammatory bowel disease and colorectal neoplasia (Table 8.1). In general, bleeding from the upper GI tract is more common than lower GI tract bleeding.


TABLE 8.1 Causes of acute upper and lower gastrointestinal (GI) bleeding



















Upper GI bleeding Lower GI bleeding
Common
• Gastric/duodenal ulcer

• Oesophageal/gastric varices
• Diverticular disease

• Angiodysplasia

• Haemorrhoids
Less common
• Gastroduodenal erosions

• Oesophagitis

• Mallory-Weiss tear
• Colonic neoplasms

• Inflammatory bowel disease

• Ischaemic colitis

• Radiation colitis

• Upper GI bleeding

• Small intestine diseases
Rare
• Upper GI malignancy

• Vascular malformation
• Colonic ulcers

• Rectal varices


High-risk patients


Significant GI bleeding is indicated by syncope, haematemesis, tachycardia (pulse rate >100 beats per minute), systolic blood pressure below 100 mmHg (13.3 kPa), postural hypotension and requiring more than 4 units of blood to be transfused within 12 hours to maintain blood pressure. Patients over 60 years of age with multiple underlying diseases (comorbidities) are at higher risk of mortality. Those admitted for comorbid medical problems (e.g. heart or respiratory failure, or a cerebrovascular bleed) who develop GI bleeding during hospitalisation also have a higher mortality risk.


In about 80% of patients, bleeding stops spontaneously before presentation. In the remaining 20% of patients, bleeding continues or recurs during hospitalisation. The mortality in this latter group increases as much as eight-fold compared with patients without further bleeding. Peptic ulcers are a very common cause of GI bleeding and haematemesis. High-risk peptic ulcers, those actively bleeding or that have bled recently, may show stigmata of haemorrhage on endoscopy. These stigmata of recent haemorrhage include active localised bleeding (i.e. pulsatile, arterial spurting or simple oozing), an adherent blood clot, a protuberant vessel or a flat pigmented spot on the ulcer base. Stigmata of haemorrhage are important predictors of recurrent bleeding.

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Mar 29, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on Haematemesis and melaena

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