Sunday, November 22, 2009

An approach to a case of Hematemesis

Hematemesis means vomiting of blood.
It can be either a frank blood, or altered, coffee-ground coloured blood (altered by digestive enzyme)
The aetiology of hematemesis is usually proximal to the duodenojejunal junction.




Causes

1) Swallowed blood

Due to hemoptysis, epitaxis

2) Oesophageal causes

Ruptured oesophageal varices
Reflux oesophagitis
Esophageal carcinoma

3) Stomach and duodenum

Peptic ulcer disease
Mallory-Weiss disease
Acute gastric erosions
Gastric carcinoma

4) Bleeding disorders

Hemophilia
Thrombocytopoenia
Coagulopathy (due to liver disease)

5) Drugs

NSAIDS
Aspirin
Steroids
Anticoagulants

6) Others

Uremia
Connective tissue disorders

History : Important questions

1) Is there any h/o of epitaxis, hemoptysis?
2) Ask for h/o of chronic liver disease
3) Any retrosternal burning chest pain radiating upwards or heartburn?
4) Any h/o of dysphagia, odynophagia, weight lost?
5) Ask for h/o of peptic ulcer disease
6) Any h/o of consumption of large meal and alcohol?
7) Does the hematemesis preceded by severe bouts of vomiting?
8) Ask for h/o of anaemia
9) Any recent h/o of acute pancreatitis? Any head injuries? (Cushing's ulcer) Or Any h/o of burns? (Curling's ulcer)
10) Any h/o of bleeding disorders? In the family, is there any?
11) Any h/o of drug intake?
12) Ask for symptoms of uraemia

On examination

1) Depends on the severity of bleeding, does the patients appears to be in shock?


Cool extremities
Prolonged capillary filling time
Tachycardia
Hypotension
Reduced skin turgosity
Altered sensorium
Sunken eyeballs
Dry tongue
Reduced urine output

2) Check around the nose - is there any blood?
3) Examine the chest for any cause of hemoptysis
4) Look for pallor
5) Look for signs of chronic liver disease
6) Any epigastric mass, palpable Left SC nodes?
7) Any epigastric tenderness?
8) Any bruises? Any signs of uremia?

Investigations

1) Full blood count, ESR


Hb level, platelet count, any raised ESR? (connective tissue disorders)

2) Liver function test
3) Coagulation profile (PT and INR)
4) BUSE (Renal profile)
5) Oesophagogastroduodenoscopy (OGD)



 

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