Emergency Medicine

UPPER GASTROINTESTINAL HAEMORRHAGE

General Medical Emergencies 77

(vi) Miscellaneous, including gastric neoplasm, blood coagulation

disorders, angiodysplasia and aorto-enteric fistula in a patient

with a past history of an abdominal aortic aneurysm (AAA)

repair.

2 Mortality is 10–14%, highest with age over 60 years, variceal origin,
comorbid disease, shock and coagulopathy.

3 Patients can present in a variety of ways:
(i) Haematemesis:
(a) fresh red blood
(b) altered blood ‘coffee grounds’.
(ii) Melaena (sticky black, tarry stool).
(iii) Haematochezia (maroon-coloured or red rectal bleeding).
(iv) Collapse and shock.
(v) Syncope and postural hypotension.
(vi) Fatigue, dyspnoea, angina, etc.

4 Ask about previous gastrointestinal bleeding, recent endoscopy, use of drugs
and alcohol, and known chronic liver disease.

5 Look for signs of volume depletion such as pallor and sweating, tachycardia,
hypotension and postural hypotension.
(i) Palpate for abdominal tenderness, organomegaly, masses, and
perform a rectal examination.
(ii) Note in particular any signs of chronic liver disease including
jaundice, bruising, spider naevi, palmar erythema, clubbing,
gynaecomastia, hepatomegaly and encephalopathy.
(iii) Examine for splenomegaly and ascites as signs of portal
hypertension.

5 Establish venous access with a large-bore 14-gauge i.v. cannula, and attach a
pulse oximeter and cardiac monitor to the patient.
(i) Take blood for FBC, U&Es, blood sugar, LFTs, clotting studies
including a prothrombin index (PTI) and cross-match from 2–4
units of blood, according to the presumed aetiology and degree of
shock.

MANAGEMENT

1 Commence high-dose oxygen via a face mask. Maintain the oxygen satura-
tion above 94%.

2 Begin f luid replacement:
(i) Start with normal saline 10–20 mL/kg, aiming for a urine output
of 0.5–1 mL/kg per hour.
(ii) Give cross-matched blood when it is available if the patient is
shocked, or if the bleeding is continuing.
(iii) Use O-negative blood if the situation is desperate.