Management of Hematemesis

Budhi Setiawan

Management of Hematemesis

• Objectives

• Risk Assessment

• Resuscitation

• Endoscopy

• Arteriography

• Tagged Red Cell Scan

• Surgical Intervention

• Drug Therapy

Objectives

• Hemodynamic resuscitation

• Cessation of bleeding source

• Prevention of future recurrence

Modified Forrest Classification for Upper GI bleeding

Class Endoscopic findings Re-bleeding

rate (%)

1a Spurting arterial vessel 80 - 90

1b Oozing hemorrhage 10 - 30

2a Non-bleeding vessel 50 - 60

2b Adherent clot 25 - 35

2c Ulcer base with black

spot sign

0 - 8

3 Clean base 0 - 12

Ulcer Appearance and Prognosis

Appearance Prevalence % Re-bleed % Mortality %

Clean base 42 5 2

Flat spot 20 10 3

Clot 17 22 7

Visible vessel 17 43 11

Active bleeding 18 55 11

Rockall Risk Stratification Score

Variable 0 1 2 3

Age (yrs)

< 60 60-80 >80

Shock

SBP>100mmHg

HR<100 bpm

SPB>100mmHg

HR>100bpm

SPB<100mmHg

Co-morbidity

No major co-morbidity Heart failure

Ischemic heart

disease

Any co-morbidity

Renal Failure

Liver disease

Disseminated

malignancy

Diagnosis

Mallory-Weiss tear. No

lesion identified. No

SSH

Malignancy of upper

GIT

Major SRH

None/Clean base.

Dark spot sign on

ulcer base

Adherent clot. Visible

vessel (non bleeding).

Oozing bleeding,

spurting arterial vessel

Resuscitation

• First thing first: ABC

• Fluid and blood replacement

• Preferably two IVs (16 or 18 gauge)

• Isotonic crystalloid solution (RL solution)

• Whole blood, packed RBCs and fresh frozen plasma

Resucitation (Cont’d)

• Nil per os

• Use of supplemental oxygen may help increase blood oxygen saturation

• Urinary catheter: accurate urine volume assessment

• Central Venous Pressure line to monitor patient’s fluid volume status

– Cardiac disease patients

Endoscopy

• Primary tool for diagnosing source of bleeding

• Before performing, may need to lavage for clearer view

• NG tube placed and room-temperature water or saline used

• Esophageal Tamponade:

• Sengstaken–Blakemore tube

• Minnesota tube

• Linton–Nachlas tube

Endoscopy (Cont’d)

• Injection:– Adrenaline (1:10,000)

– Sclerosant (sodium morrhuate, sodium tetradecyl sulfate, and ethanolamine oleate)

– Alcohol

– Fibrin glue (a mixture of thrombin & fibrinogen)

• Ablation:– Heater probe

– Bipolar Coagulation (BICAP)

– Argon Plasma

• Mechanical devices:– Endoclips or banding (small elastic bands)

Angiography

• For patients with obscure, continuous UGIBs

• Intra-arterial vasopressin

• Embolization (glue, gelfoam, sclerosant, coil)

• Can detect bleeding rate > 0.5 mL/min

• CT Angiography (CTA) is faster, easier, and more sensitive at detecting active bleeding (Dx only)

Tagged Red Cell Scan

• Technetium 99m-labeled red blood cell scan

• Detection of bleeds that are much slower(0.1– 0.4 mL/min.)

• Recommended before angiography

• It lowers the risk of complications from angiography

Transjugular intrahepatic portosystemic shunt (TIPS)

• It creates a communication through the hepatic parenchyma between the hepatic and portal veins.

• Methods of treating the portal hypertension.

• Complications:

– Intraperitoneal hemorrhage, right-sided heart failure, decompensated liver failure, shunt dysfunction and hepatic encephalopathy.

Surgical Intervention

Drug Therapy• Proton Pump Inhibitor

– Irreversibly blocking the H+/K+ ATPase system of the gastric parietal cells.

– It reduces recurrent bleeding, hospital stay, bood transfusion.

– It has no effect on mortality.

– Omeprazole, Lansoprazole, Pantoprazole etc

• H2 Receptor Antagonist

– Histamine H2-receptor antagonists (H2 blockers).

– No significant improvement in outcomes.

– cimetidine, ranitidine, famotidine

Drug Therapy (Cont’d)• Vasopressin:Telipressin

– An analogue of the natural hormone argininevasopressin

– It stimulates vasopressin-1 receptors

– It may reduce relative risk in mortality

• Somatostatin:Octreotide– A synthetic somatostatin analogue

– Splanchnic vasoconstriction

• Recombinant human factor VIIa (rFVIIa)– If a coagulopathy has been detected

– No greater benefit compares to placebo

Drug Therapy (Cont’d)

• Antibiotics– Portal Hypertension

• Increase of infection risk

– H.Pylori Infection

• Omeprazole, amoxicillin, and clarithromycin

• Omeprazole, metronidazole, and amoxicillin/clarithromycin,

– Erythromycin

• To aid gastric motility and emptying

• Promotes evacuation of intragastric blood and improves endoscopic visualization

Drug Therapy (Cont’d)

• Beta Blocker (Propranolol or Nadolol)

– For portal hypertension pasient

– It may lower portal venous pressure

• Prostaglandin analogue (Misoprostol)

– When patients must be administered NSAIDs

• Tranexamic acid

– An antifibrinolytic agent

– It is not often used

– It could lead to venous thrombosis

THANK YOU