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CDHB

Haematemesis

Causes

• Mallory-Weiss tear.
• Acute stress erosions (shock, sepsis, NSAID).
• Peptic ulceration (ask about NSAID + aspirin use).
• Varices including gastric (note: high mortality).
• Oesophagitis.
• Upper GI tract cancer.
• Abnormal haemostasis.
• Swallowed blood.

Management

See also: Upper Gastrointestinal Bleeding Pathway in the Emergency Department (search for "C240071" on the CDHB intranet).

Resuscitation takes precedence over diagnostic investigations. Gastroscopy should normally be performed within the first 24 hours. Early consultation, if therapeutic procedures such as injection of bleeding ulcers, or banding of varices are likely to be required. A patient who continues to bleed heavily may require immediate surgery without other investigation unless varices suspected.

• Assess degree of blood loss (see Shock):
  • History often unreliable.
  • Useful signs include:
    • Resting tachycardia.
    • Hypotension.
    • Postural BP drop >15 mm Hg.
• Stabilize patient and monitor:
  • Give sodium chloride 0.9% IV, then blood when available.
  • Use Group O Rh negative blood in an emergency. See Collection of Blood from Blood Bank.
• Initial investigations:
  • Crossmatch 6 units of resuspended red cells.
  • CBC + diff.
  • Coagulation profile.
  • Na, K, creatinine, urea, LFTs.

Urgent surgical consultation if:

• More than 3 units of blood need to be transfused.
• Continuing or prolonged bleeding.
• Perforation suspected. 

Gastroenterology consultation

• The prognosis is relatively favourable if the age is <60 with no shock or co-morbidities and the likely cause is a Mallory-Weiss tear. The outlook is poor for older patients >80, with haemodynamic instability and multiple comorbidities.
• Urgent consultation is generally indicated, especially if there are poor prognostic features.
• Gastroscopy should be considered and done urgently if varices are suspected as they may require endoscopic therapy. Otherwise it should be done within 24 hours.

Therapy

Varices

• Consult Gastroenterologist.
• Terlipressin 1-2 mg IV bolus stat, then 1 mg q4h as an IV bolus. Use with caution if known ischaemic heart disease or other vascular disease due to vasoconstrictor effect.
• Octreotide is an alternative. Commence an IV infusion of octreotide using a 50 microgram bolus followed by a continuous infusion (25 - 50 microgram/hour) for up to 72 hours.
• Administer prophylactic antibiotics, e.g., cefotaxime, ceftriaxone.
• Urgent variceal ligation or occasionally sclerotherapy.
• Sengstaken-Blakemore or Linton tube and transfer to ICU if bleeding not controlled by endoscopy. (Consider endotracheal intubation first to reduce the risk of aspiration if level of consciousness is impaired.)

Peptic ulceration

• Acute bleeding from a peptic ulcer. High dose omeprazole infusion is beneficial in specific situations. This will be directed by the Gastroenterologist. This regimen may be followed:
• Regimen:
  • Bolus omeprazole IV injection: 80 mg stat loading dose

    Followed immediately by:

  • Continuous omeprazole IV infusion: 8 mg/hour for 72 hours.
  • Oral omeprazole 20 mg once daily should be commenced at the end of the 72-hour infusion period.

  Alternatively, if the omeprazole infusion product is unavailable, use:

  • Bolus omeprazole IV injection: 80 mg stat

    Followed in 6 hours by:

  • Omeprazole IV injection 40 mg every 6 hours. The total duration of IV treatment should be 72 hours.
  • Oral omeprazole 20 mg once daily should be commenced at the end of the IV treatment period.
• Administration:

  Bolus omeprazole IV injection

  • When administering the bolus injection, it is important to use the IV injection product, NOT the IV infusion product. These two formulations are different and are not interchangeable due to stability concerns.
  • Reconstitute each 40 mg vial with the diluent provided, according to the guidelines in the package insert, i.e., 4 mg/mL.
  • Administer reconstituted vial by direct IV injection (into vein or side arm) over at least two and a half minutes at a rate not exceeding 4 mL/min (5 minutes for 80 mg).

  Continuous omeprazole IV infusion

  • When administering the continuous infusion, it is important to use the IV infusion product, NOT the IV injection. These two formulations are different and are not interchangeable due to stability concerns.
  • Reconstitute a 40 mg vial of omeprazole infusion, add to an infusion bag according to the guidelines in the package insert (Dr Reddy's is 100 mL glucose 5%) and infuse over 5 hours (8 mg/hr).
  • Repeat for a total continuous infusion of 72 hours (unless stopped after a diagnosis is made at endoscopy).
• Use of bolus dose intravenous omeprazole in other clinical situations

  Intravenous omeprazole is only indicated if patients are unable to take oral or enteral formulations (i.e., difficulty swallowing, vomiting, non-functioning gut). In these cases patients should receive IV bolus omeprazole in a dose equivalent to what they would be expected to receive orally.

Helicobacter pylori

• Eradication therapy for Helicobacter pylori when this has been identified. Give oral treatment with omeprazole 20 mg BD + amoxicillin 1 g BD + clarithromycin 500 mg BD for 7 days. If penicillin allergy, substitute metronidazole 400 mg BD for amoxicillin.

Other regimens are available for treatment failures. Consult Gastroenterology.

Topic Code: 1407