Management of Haematemesis and Melæna PDF

Management of haematemesis and melaena/ Dr. Yousif Al-Jubori MANAGEMENT OF HAEMATEMESIS AND MELAENA Upper gastrointestinal bleeding (UGIB) is a common medico-surgical emergency problem. It is defined as; bleeding from lesions of the oesophagus, stomach, or duodenum. Presentations of UGIB: Patients...

Management of haematemesis and melaena/ Dr. Yousif Al-Jubori MANAGEMENT OF HAEMATEMESIS AND MELAENA Upper gastrointestinal bleeding (UGIB) is a common medico-surgical emergency problem. It is defined as; bleeding from lesions of the oesophagus, stomach, or duodenum. Presentations of UGIB: Patients with upper gastrointestinal bleeding are usually presented with: 1. Haematemesis; (vomiting of blood or blood clots). 2. Melaena; (passage of dark tarry stool). 3. Both haematemesis and melaena. 4. Hypovolaemic shock due to the severe bleeding. Aetiology of bleeding: Aetiology of the bleeding is classified into local and general causes. The local causes are more common than general causes. 1. Local oesophageal causes of the bleeding: a. Oesophageal peptic ulcer due to reflux oesophagitis (GERD). b. Oesophageal varices; (dilated veins at the lower oesophagus due to liver cirrhosis and portal hypertension). c. Mallory–Weiss syndrome; (mucosal tear at the gastro-oesophageal junction due to repeated severe vomiting after large meal or alcohol consumption). d. Oesophageal tumours; (benign and malignant). 2. Local gastric causes of the bleeding: a. Acute gastritis and gastric erosions; (small ulcers < 5 mm; which are caused by ingestion of aspirin, NSAIDs and corticosteroids). b. Gastric peptic ulcer. c. Gastric tumours; (benign and malignant). 3. Local duodenal causes of the bleeding: a. Acute duodenitis. d. Duodenal peptic ulcer. 4. General causes of the bleeding: a. Blood disease; (e.g., haemophilia, leukaemia, or thrombocytopenia). b. Anticoagulant therapy; (e.g., heparin or warfarin). MANAGEMENT OF HAEMATEMESIS AND MELAENA The management of haematemesis and/ or melaena is threefold: 1  Management of haematemesis and melaena/ Dr. Yousif Al-Jubori 1. Resuscitation of the patient. 2. Diagnosis of the source of bleeding. 3. Treatment of the source of bleeding. RESUSCITATION OF THE PATIENT (ABC) 1. Airway and breathing assessment: A priority of the patient’s airway and breathing is always undertaken; and oxygen is administered when necessary. 2. Fluid replacement and blood transfusion are immediately started. 3. Monitoring of the patient’s general condition to exclude features of shock; (e.g., pulse rate, blood pressure, and urine output). DIAGNOSIS OF THE SOURCE OF BLEEDING History and clinical examination: Once resuscitation is under taken, a history and clinical examination should be taken to establish the possible aetiology of the bleeding. Special investigations: 1. Haemoglobin and packed cell volume are useful estimations as a baseline. 2. Coagulation screen to exclude any bleeding tendency; (e.g., platelet count, bleeding time, clotting time, prothrombin time and partial thromboplastin time). 3. Diagnostic upper gastrointestinal endoscopy (OGD): This is the most valuable investigation, which is carried to identify the exact site and cause of bleeding. TREATMENT OF THE SOURCE OF BLEEDING 1. Treatment of the bleeding is mostly started with conservative measures according to the cause. 2. Laparotomy: If upper gastrointestinal bleeding fails to stop on conservative treatment, the source of bleeding is viewed at operation and treated directly. 3. Oral fluids and light diet are started when the patient stops vomiting and active bleeding ceases. 2