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
1a

Endoscopic findings
Spurting arterial vessel

Re-bleeding rate (%) 80 - 90 10 - 30 50 - 60

25 - 35 0-8

1b 2a
2b 2c

Oozing hemorrhage Non-bleeding vessel

Adherent clot Ulcer base with black spot sign Clean base

0 - 12

Ulcer Appearance and Prognosis

Appearance
Clean base
Flat spot Clot

Prevalence % Re-bleed % Mortality %

42
20 17

5
10 22

2
3 7

Visible vessel
Active bleeding

17
18

43
55

11
11

Rockall Risk Stratification Score

Variable
< 60

0
60-80

1
>80

Age (yrs)
SBP>100mmHg HR<100 bpm SPB>100mmHg HR>100bpm SPB<100mmHg

Shock

No major co-morbidity

Co-morbidity
Mallory-Weiss tear. No lesion identified. No SSH
None/Clean base. Dark spot sign on ulcer base

Heart failure Ischemic heart disease Any co-morbidity

Renal Failure Liver disease Disseminated malignancy

Diagnosis

Malignancy of upper GIT

Major SRH

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 (Contd)
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 patients 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:
SengstakenBlakemore tube Minnesota tube LintonNachlas tube

Endoscopy (Contd)
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 signicant improvement in outcomes. cimetidine, ranitidine, famotidine

Drug Therapy (Contd)

Vasopressin:Telipressin
An analogue of the natural hormone arginine vasopressin 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 (Contd)

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 (Contd)

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