History taking
• Complaints Haematemesis Malena Haemotochezia Pain Light-headedness, syncope, dyspnoea, altered mental status (blood loss symptoms) occult blood loss (anaemia)
Clinical Indicator Probability of Upper GI Source
Probability of Lower GI Source
Hematemesis Almost certain Rare
Melena Probable Possible
Hematochezia Possible Probable
Blood-streaked stool Rare Almost certain
Occult blood in stool Possible Possible
Contd.,
• H/o Drug intake – Aspirin, Anticoagulants (warfarin), NSAIDS, Clopidogrel, steroids
• H/o Alcohol intake, smoking• H/o Weight loss
Past History :Chronic liver disease, peptic ulcer, bleedingDisorders
Examination
• General ExaminationMental statusEyes – Pallor, JaundiceLiver disease – caput medusae, spider angiomas,
ascites, palmar erythema, flapBleeding disorders – Petechia, echymosis
Vital Signs – BP, HR, SaO2, RR, T⁰, CRF Urine output
Examination – contd.,
• Abdominal Inspection – Shape, symmetry, Dilated Veins, signs
of liver failure Palpation – tenderness, Splenomegaly, hepatomegaly Percussion – Shifting dullness, Fluid thrill Auscultation – BS, Bruit Rectal Examination – Fresh blood, MalenaCVS, RS, Neurological Examination
Investigation
• FBC, Coagulation profile, U&ES, LFT, CRP, Calcium• Type and Crossmatch Blood• ECG• CXR• OGD• Angiogram CT or Catheter• Nasogastric lavage• USS/CT (to assess liver disease)• Tc-99m-labeled erythrocyte scans (rarely)
Management
• RESUSCITATION – ABCDE• Fluid and BLOOD Replacement• Medical Management - PPIs, Vasoactive agents,
B-blocker, ISMN (to prevent re-bleeding)• Endoscopic management – Adrenaline,
coagulation, banding, clipping• Interventional Angiography – coiling, TIPS• Surgical Management
Haemorrhagic ShockEstimated Fluid and Blood Losses in Shock
Class 1 Class 2 Class 3 Class 4
Blood Loss, mL
Up to 750 750-1500 1500-2000 >2000
Blood Loss,% blood volume
Up to 15% 15-30% 30-40% >40%
Pulse Rate, bpm
<100 >100 >120 >140
Blood Pressure
Normal Normal Decreased Decreased
Respiratory Rate
Normal or Increased
Decreased Decreased Decreased
Urine Output, mL/ h
14-20 20-30 30-40 >35
CNS/ Mental Status
Slightly anxious
Mildly anxious
Anxious, confused
Confused, lethargic
Fluid Replacement, 3-for-1 rule
Crystalloid Crystalloid Crystalloid and blood
Crystalloid and blood
Glasgow-Blatchford Score
Scores of 6 or more were associated with a greater than 50% risk of needing an intervention
Sengstaken-Blakemore tube
Child Pugh classification
Further reading/References
• Clinical Anatomy: Applied Anatomy for Students and Junior Doctors by Prof H Ellis
• Review Of Medical Physiology by W F Ganong• Guidelines - http://guidance.nice.org.uk/CG141 - http://www.sign.ac.uk/guidelines/fulltext/105