1. Management of a Pt with Hematemesis
Dr. Salem Mohammad Bazarah
MD, M.Ed, FACP, FRCPC, FRCPC (GI) & PhD
Management of a Pt with Hematemesis

2. A common medical condition
250,000 – 500,000 admissions/year US
UGI bleeding incidence 100/100,000 adults
Incidence increases fold from third to ninth decade of life
LGI bleeding incidence 20/100,000 adults
Overwhelmingly disease of the elderly
GI bleeding stops spontaneously in 80 %

3. Morbidity Data Majority will receive blood transfusions
2 – 10 % require urgent surgery to arrest bleeding
Average LOS 4 – 7 days
Mortality rates for UGI bleeding 2 – 15 %
Mortality for patients who develop bleeding after admission to hospital for another reason is 20 – 30 %

4. Costs Average hospital costs exceed $ 5,000 per admission
Most of this for hospital bed and ICU stays rather than physician fees, blood products, diagnostic tests, or medications
Reduction of hospital admissions and LOS has greatest potential to reduce costs

5. UGI bleeding:Nomenclature
Hematemesis 25 %
Melena alone 25 %, 50 – 100 cc of blood will render stool melenic
Hematochezia 15 %, seen in massive UGI hemorrhage
“Red blood” hematemesis
“Coffee ground” emesis

8. Indications for Hospitalization and Intensive Care
Traditional: Endoscopy on the day of admission or on the day after
Recent studies: Complete endoscopic risk stratification PRIOR to admission
Between % of patients with UGI bleeding could be discharged from the Emergency Department

9. Predictors of Outcome in UGI bleeding
Clinical
Endoscopic
Age > 60 y
Low risk endoscopic findings
Hemodynamic instability
High risk endoscopic findings
Comorbidities
Hematemesis (red blood)
Coagulopathy

10. Ulcer Appearance and Prognosis
Prevalence %
Rebleed %
Mortality %
Clean base 42 5 2
Flat spot 20 10 3
Clot 17 22 7
Visible vessel 43 11
Active bleeding 18 55

18. History
45 yrs male with 1 day hx of vomiting blood

19. Approach Assess the severity Resuscitate
Establish the site of bleeding
Endoscopic intervention
Reassess severity: liase with surgical team
Medical treatment
Indications for surgery

20. Assessing severity: Rockall criteria
Criterion Score
Age <60 years 0
60-79 yrs 1
>80 years 2
Shock None 0
Pulse & sBP >100 1
sBP <
Co-morbidity None 0
Cardiac/any major 2
Renal/liver/malig. 3
Total initial score (max = 7)

21. Implications of initial score
Initial risk score (pre-endoscopy)
Score Mortality
0 0.2%
1 2.4%
2 5.6% % % % % %
Rockall TA et al Gut 1996; 38:

22. Resuscitate Large bore intravenous cannula x 2
X-match 4 units, give colloid & transfuse if
Fresh melaena on PR
Postural hypotension >15mm/Hg
sBP <100mmHg
Cross match 6 units for
Suspected variceal bleeding
Otherwise group and save serum only

23. Resuscitation Indications for CVP Urea/creatinine ratio
Rockall score > 3, first rebleed, or inadequate access
Insert urinary catheter if CVP appropriate
Urea/creatinine ratio
If >unity (eg 12.4/90), then upper GI bleed likely
Monitor Pulse & BP ‘?hrly’
Guide of halves: if pulse higher or BP lower than last recording, then halve the time to the next recording
If pulse trend rises on 3 occasions, call senior cover

24. Establish site of bleeding
Endoscopy on next available list
Ideally <24hr
Out of hours endoscopy
If a surgical decision depends on the result
Therefore consent ‘endoscopy, ?proceed’
Check endoscopy report for
stigmata of recent haemorrhage
intervention

25. Stigmata of recent haemorrhage
Clean ulcer base (rebleed <1%)
Black spots ulcer base (rebleed 5%)

26. Stigmata of recent haemorrhage
Fresh clot (rebleed 30%)
Visible vessel (rebleed 50%)

27. Stigmata of recent haemorrhage
Bleeding vessel (rebleed 80%)

28. Upper GI Bleeding
Klaus Gottlieb, MD, FACP, FACG

29. Source of bleeding Common DU (35%) GU (20%) Oesophagitis (6%)
Mallory-Weiss (6%)
No source found (20%)
Uncommon/Rare
Varices
Tumour
Aortoenteric fistula
Dieulafoy
Haemobilia
Angiodysplasia

30. Do not prescribe iv ranitidine, or oral PPI until after endoscopy
Intervention
Endoscopic injection with
Adrenaline 1:10 000, thrombin, sclerosant, or saline all halve the risk of rebleeding
As good as heater probe, laser therapy
Tranexamic acid
1g iv three times daily for 72hr reduces mortality
Omeprazole 60mg iv stat and infusion 8mg/hr for 72hr
may reduce mortality after endoscopic intervention
Nothing else has been shown to work
Do not prescribe iv ranitidine, or oral PPI until after endoscopy

31. Reassess severity: update Rockall
Score
Endoscopic diagnosis
No lesion, or M-W tear
All other diagnoses
Malignancy of upper GI tract 2
Stigmata of recent haemorrhage
None/haematin
Clot, visible vessel,blood in stomach 2
Final score after endoscopy (max 11)

32. Updated Rockall score Initial score (pre- endoscopy)
Score Mortality % % % % % % % %
Final score (after endoscopy)
Score Mortality
0 0%
1 0%
2 0.2%
3 2.9%
4 5.3% % % %

33. Further management Liase with surgeons if After endoscopy
Initial score >3 (ie if CVP necessary)
Posterior duodenal ulcer
Final Rockall score >4
After endoscopy
Eat & drink if no stigmata, or haematin only
Clear fluids for 12 hr if endoscopic intervention
NBM only if haemostasis not secure (varices)
Re-examine after 4-8hr for signs rebleeding
Ring blood bank to keep blood available for 24hr after endoscopic intervention

34. Signs of rebleeding Rise in pulse rate Fall in CVP
Decrease in hourly urine output
Further haematemesis or fresh melaena
Look at the patient as well as the charts!
Act if rebleeding suspected
FBC and transfuse
Ensure large bore access, central line and catheter
Call surgical team

35. Indications for surgery
Early surgery (esp. elderly) assoc. with lower mortality
Age over 60 years
Transfusion >4 units in 24hr
One rebleed
Continued bleeding
Age under 60 years
Transfusion >8 units in 24hr
Two rebleeds
Decision not to operate should be taken by consultant

36. Special notes - Variceal bleeding
Suspect variceal bleeding if… Alcohol Hx - Deranged LFT’s - Jaundice* - Hyponatraemia* - Ascites* - Coagulopathy - Low platelets - Previous Hx of varices*

37. Special notes – Variceal Bleeding
Resuscitate
Correct coagulopathy (FFP x 4 and vit K IV)
Endoscopy and banding/sclerotherapy
Glypressin 2mg iv stat and 1-2mg repeated 4hrly
Treat other aspects of decompensation
Ascites (spironolactone, no N/saline)
Encephalopathy (lactulose, no sedation)
Renal impairment (avoid hypovolaemia)
Malnutrition (iv vitamins, fine bore feeding)
Underlying liver disease (hepatic ‘screen’, aFP etc)
Post-bleed prophylaxis

38. Summary Objective assessment (Rockall criteria)
Resuscitation before endoscopy
Monitor by rule of halves: look for trends
No role for empirical acid suppression
Critical appraisal of endoscopy report
Liaise with surgeons early
Discriminate between high & low risk patients