Haematemesis

Essentials

• Prevent the threatening haemorrhagic shock.
• If the bleeding continues, organize the transfer of the patient to a surgical unit.
• Find the cause and stop the bleeding.

Epidemiology

• The annual incidence is 0.5-1 per 1 000 persons.
• More than 5% of surgical emergency patients have acute gastrointestinal bleeding, and 80% of them have upper gastrointestinal bleeding.

History

• The patient's history can yield clues of the underlying cause, but it seldom has any effect on the acute management of the bleeding patient.
• Important factors in the patient's history are
  • continuous use of analgesics (NSAIDs) and glucocorticoids (gastric ulcer and erosions)
  • possible anticoagulant therapy
  • previous ulcer history
  • previous operations
  • liver cirrhosis (variceal bleeding).

Clinical findings

• The severity of the bleeding is estimated by clinical examination.
• High-risk bleeding is suggested by
  • sudden onset
  • signs of hypovolaemic shock at arrival to the hospital
  • low blood haemoglobin concentration
  • age over 65 years
  • multiple associated diseases
  • vomiting of ample amounts of fresh blood or detection of red blood in digital rectal examation.
• Patient in a haemorrhagic shock is pale and coldsweating, the pulse is rapid and thin and the blood pressure is low. When evaluating the fall in blood pressure one must take into account the patient's initial BP level.
• Rectal examination is mandatory in every patient with haematemesis. Melaena (dark, tarry faeces) tells that the patient has had the bleeding already for some hours. Normal colour of the faeces does not rule out bleeding. In extremely severe upper gastrointestinal bleeding the faeces can be clearly bloody (haematochezia).
• Note the signs of a chronic liver disease:
  • large or hard liver on palpation
  • spider naevi, palmar erythema
  • gynaecomastia
  • jaundice.
• Teleangiectasias in Osler's syndrome (mouth, lips, skin); see http://www.orpha.net/consor/cgi-bin/Disease_Search.php?data_id=236

Primary investigations

• In severe, continuous bleeding, the treatment must be started immediately and the patient must be transported to a surgical unit.
• In case of slower bleeding or if the diagnosis is uncertain, the determination of blood haemoglobin concentration can be useful. Haemoglobin < 100 g/l usually means an increased risk, but the patient may have low haemoglobin concentration without shock, if the bleeding has been slow (lasting for several days). On the other hand, even quite a heavy acute bleeding can cause only a slight decrease in the haemoglobin concentration.

Initial treatment

• If significant bleeding is suspected, an i.v. infusion is started.
• If the patient is in shock, two i.v. cannulas should be inserted, as necessary.
• Blood volume is corrected. Use balanced electrolyte solutions. The aim of the volume substitution is systolic blood pressure of 90-100 mmHg.
• If the bleeding is profuse, i.e. the patient is in shock, the receiving hospital should be called in advance. Overloading with parenteral fluids must be avoided.
• After blood transfusion is available (usually at the receiving unit), the haemoglobin concentration is restored to the level of 90 g/l in order to avoid hypoxia (the patients are often old and they may have coronary artery disease or disturbances of the cerebral circulation).
• In the surgical unit, intravenous fluid therapy is continued, blood type compatible red blood cell transfusions are initiated as soon as possible, and in profuse bleeding, also coagulation factors are administered.
• Endoscopic treatment is preferred. Endoscopy should be performed immediately on a bleeding patient in shock, and within 24 hours on a high risk patient. After the bleeding has stopped, endoscopy is performed during the same hospital visit.

Aetiology and treatment of haematemesis