Haematemesis and malena

HAEMATEMESIS & MELAENA

Seminar Prepared by:
Mohammed Musa
Mohammed Saadi
Safa Sami

Surgery
College of Medicine - University of Kirkuk

1. HAEMATEMESIS & MELAENA

2. Haematemesis is the vomiting of blood from the upper GI tract . Bright red blood or clots imply active bleeding and are a medical emergency. Altered blood with a dark, granular appearance (‘coffee-grounds’) suggests that bleeding has ceased or has been relatively modest . This must be differentiated from haemoptysis when the blood is coughed up.

3. Melaena refers to the black, tarry stool produced in the presence of upper gastrointestinal haemorrhage. The black appearance of the stool is caused by oxidation of iron in the haemoglobin as it passes through the ileum and colon.

4. Incidenc e : Upper gastrointestinal haemorrhage remains a major medical problem with an incidence of over 100/100 000 per year in Western practice that increases with increasing age. Haemorrhage is strongly associated with NSAID use . Despite improvements in diagnosis and the proliferation in treatment modalities over the last few decades, an in-hospital mortality of 5–10 per cent can be expected. This rises to 33 per cent when bleeding is first observed in patients who are hospitalised for other reasons .

5. Presentation : Haematemesis with or without melaena . There may be associated symptoms of lethargy, dizziness, shortness of breath, abdominal or retrosternal pain. There may be signs of hypovolaemic shock.

6. Causes of upper gastrointestinal bleeding:

7. Emergency Management Whatever the cause, the principles of management are identical. First , the patient should be adequately resuscitated and, following this, the patient should be investigated urgently to determine the cause of the bleeding. Only then should treatment of a definitive nature be instituted.

8. For any significant gastrointestinal bleed, intravenous access should be established and, for those with severe bleeding, central venous pressure monitoring should be set up and bladder catheterisation performed . Blood should be cross-matched and the patient transfused as clinically indicated, usually when >30 per cent of blood volume has been lost. There is no evidence for the use of intravenous proton pump inhibitors prior to endoscopy. As a general rule, most gastrointestinal bleeding will stop, albeit temporarily, but there are sometimes instances when this is not the case. In these circumstances, resuscitation, diagnosis and treatment should be carried out simultaneously.

9. There are occasions when life saving manoeuvres have to be undertaken without the benefit of an absolute diagnosis For instance, in patients with known oesophageal varices and uncontrollable bleeding, a Sengstaken– Blakemore tube may be inserted before an endoscopy has been carried out. This practice is not to be encouraged, except in extremis. In some patients, bleeding is secondary to a coagulopathy . The most important current causes of this are liver disease and inadequately controlled warfarin therapy. In these circumstances the coagulopathy should be corrected, if possible, with fresh-frozen plasma or concentrated clotting factors.

10. Initial assessment and risk stratification: Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed. Blood transfusions should target hemoglobin >= 7 g/dl, with higher hemoglobins targeted in patients with clinical evidence of intravascular volume depletion or comorbidities, such as coronary artery disease. Risk assessment should be performed to stratify patients into higher and lower risk categories and may assist in initial decisions such as timing of endoscopy, time of discharge, and level of care .

11. Discharge from the emergency department without inpatient endoscopy may be considered in patients with: urea nitrogen < 18.2 mg/dl; hemoglobin >= 13.0 g/dl for men (12.0 g/dl for women), systolic blood pressure >= 110 mm Hg; pulse < 100 beats / min; and absence of melena , syncope, cardiac failure, and liver disease, as they have < 1% chance of requiring intervention.

12. After Stabilization Upper gastrointestinal endoscopy should be carried out by an experienced operator as soon as practicable after the patient has been stabilised. In patients in whom the bleeding is relatively mild, endoscopy may be carried out on the morning after admission. In all cases of severe bleeding it should be carried out immediately . A number of scoring systems have been advocated for the assessment of rebleeding and death after upper gastrointestinal haemorrhage.

13. Perhaps the most useful of these is the Rockall score. This can be used in a pre-endoscopy format to stratify patients to safe early discharge and postendoscopy it can relatively accurately predict rebleeding and death.

14. Pre-endoscopic medical therapy Intravenous infusion of erythromycin (250 mg ~30 min before endoscopy) should be considered to improve diagnostic yield and decrease the need for repeat endoscopy. However, erythromycin has not consistently been shown to improve clinical outcomes. Pre-endoscopic intravenous PPI (e.g., 80 mg bolus followed by 8 mg/h infusion) may be considered to decrease the proportion of patients who have higher risk stigmata of hemorrhage at endoscopy and who receive endoscopic therapy. However, PPIs do not improve clinical outcomes such as further bleeding, surgery, or death. If endoscopy will be delayed or cannot be performed, intravenous PPI is recommended to reduce further bleeding.

15. Gastric lavage : Nasogastric or orogastric lavage is not required in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic effect .

16. Timing of endoscopy: Patients with UGIB should generally undergo endoscopy within 24 h of admission, following resuscitative efforts to optimize hemodynamic parameters and other medical problems. In patients who are hemodynamically stable and without serious comorbidities endoscopy should be performed as soon as possible in a non-emergent setting to identify the substantial proportion of patients with low-risk endoscopic findings who can be safely discharged.

17. In patients with higher risk clinical features (e.g., tachycardia, hypotension, bloody emesis or nasogastric aspirate in hospital) endoscopy within 12 h may be considered to potentially improve clinical outcomes.

18. Endoscopic therapy: Endoscopic therapy should be provided to patients with active spurting or oozing bleeding or a non-bleeding visible vessel. Endoscopic therapy may be considered for patients with an adherent clot resistant to vigorous irrigation. Benefit may be greater in patients with clinical features potentially associated with a higher risk of rebleeding (e.g., older age, concurrent illness, inpatient at time bleeding began ). Endoscopic therapy should not be provided to patients who have an ulcer with a clean base or a flat pigmented spot.

19. Epinephrine therapy should not be used alone. If used, it should be combined with a second modality. Thermal therapy with bipolar electrocoagulation or heater probe and injection of sclerosant (e.g., absolute alcohol) are recommended because they reduce further bleeding, need for surgery, and mortality.

20. Clips are recommended because they appear to decrease further bleeding and need for surgery. However, comparisons of clips vs. other therapies yield variable results and currently used clips have not been well studied. For the subset of patients with actively bleeding ulcers, thermal therapy or epinephrine plus a second modality may be preferred over clips or sclerosant alone to achieve initial hemostasis .

21. Medical therapy after endoscopy After successful endoscopic hemostasis, intravenous PPI therapy with 80 mg bolus followed by 8 mg/h continuous infusion for 72 h should be given to patients who have an ulcer with active bleeding, a non-bleeding visible vessel, or an adherent clot. Patients with ulcers that have flat pigmented spots or clean bases can receive standard PPI therapy (e.g., oral PPI once daily ).

22. Repeat endoscopy Routine second-look endoscopy, in which repeat endoscopy is performed 24 h after initial endoscopic hemostatic therapy, is not recommended. Repeat endoscopy should be performed in patients with clinical evidence of recurrent bleeding and hemostatic therapy should be applied in those with higher risk stigmata of hemorrhage. If further bleeding occurs after a second endoscopic therapeutic session, surgery or interventional radiology with transcathether arterial embolization is generally employed.

23. Algorithm for management of haematemesis and melaena .

24. Peptic ulcer

25. Peptic ulcer Gastric ulcer Duodenal ulcer

26. Bleeding peptic ulcers The epidemiology of bleeding peptic ulcers exactly mirrors that of perforated ulcers. In recent years, the population affected has become much older and the bleeding is commonly associated with the ingestion of NSAIDs. Diagnosis can normally be made endoscopically, although occasionally the nature of the blood loss precludes accurately identifying the lesion. However, the more experienced the endoscopist, the less likely this is to be a problem.

27. Medical and minimally interventional treatments Medical treatment has limited efficacy. All patients are commonly started on either an H2-antagonist or a proton pump antagonist, and recent evidence confirms the benefit of proton pump inhibitor administration to prevent rebleeding after endoscopy. Furthermore , meta-analysis of studies suggests that tranexamic acid, an inhibitor of fibrinolysis, may reduce overall mortality.

28. Therapeutic endoscopy can achieve haemostasis in approximately 70 per cent of cases, with the best evidence supporting a combination of adrenaline injection with heater probe and/or clips. Therapeutic endoscopy will probably never be effective in patients who are bleeding from large vessels and with which the majority of the mortality is associated.

29. In patients where the source of bleeding cannot be identified or in those who rebleed after endoscopy, angiography with transcatheter embolisation may offer a valuable alternative to surgery in expert centres. The risk of significant ischaemia following embolisation is low because of the rich collateral blood supply of the stomach and duodenum. A fter failed embolisation is associated with poor outcome and it may be advantageous to proceed directly to surgery.

30. Surgical treatment if bleeding persists, or recurs despite endoscopic intervention surgery, should attempted factors which should encourage surgical intervention: - A large vessel, visible in the ulcer base - a major initial bleed, - a re-bleed in hospital - advanced age - Patient who has required more than 6 units

31. The aim of the operation is to stop the bleeding The most common site of bleeding from a peptic ulcer is the duodenum the duodenum, and usually the pylorus, are opened longitudinally bleeding controlled by using well-placed sutures that under-run the vessel Pyloroplasty is then closed with interrupted sutures in a transverse direction Bleeding G.U same line +biopsy or excision Definitive acid lowering surgery is not now required very large ulcer eroding into a major branch of the left gastric artery may necessitate a subtotal gastrectomy incorporating the ulcer

32. Long-term prevention of recurrent bleeding ulcers

33. E rosive gastritis Destruction of the mucosa of the stomach Common Causes ( NSAIDs , Alcohol and Stress ) Treatment is supportive by changing the non selective NSAIDs to selective cox 2 inhibitor and stop alcohol and taking prophylactic antacids Surgical treatment is required in severe gastritis (total gastrectomy )

34. Mallory–Weiss tear This is a longitudinal tear at the gastro-oesophageal junction, which is induced by repetitive and strenuous vomiting . Doubtless , many such lesions occur and do not cause bleeding. When it is a cause of haematemesis, the lesion may often be missed as it can be difficult to see as it is just below the gastrooesophageal junction, a position that can be difficult for the inexperienced endoscopist.

35. Occasionally, these lesions continue to bleed and require surgical treatment. Often the situation arises in which the surgeon does not have guidance from the endoscopists as regards the site of bleeding, and a high index of suspicion in such circumstances is important. The experienced surgeon will perform on-table endoscopy prior to embarking on surgery. The stomach is opened by longitudinal gastrotomy and the upper section is carefully inspected. It is normally possible to palpate the longitudinal mucosal tear with a little induration at the edges, which gives a clue to the lesion’s location. Underrunning is all that is required.

36. P ortal hypertensi ve gastropathy

37. P ortal hypertensi ve gastropathy Refers to change in the mucosa of the stomach in patient with portal hypertension , most common cause is liver cirrhosis and portal vein thrombosis which lead to gastric varices and esophageal varices that tend to rupture and perforate causing bleeding By endoscopic intervention can determine the varices The first line of treatment is by band ligation therapy and if it is failed , then doing transjugular intrhepatic portosystemic shunt (TIPS )

38. Tumours Can be beningn or malignant Beningn tumours of the stomach and duodenum are not common and constitute only 5 -10 % of all stomach tumours ,it is either epithelial, mesenchymal , vascular , neurogenic The most commn presenting symptom is bleeding Treatment is endoscopic resection or by open surgery

39. Most common malignant tumours 1- Adenocarcinoma 95%‎ 2 -Lymphoma 4‎%‎ 3 -Malignant gastrointestinal stromal tumour 1% Treatment is by excision of tumor (total or subtotal gasterectomy ) with chemo or radiotherapy if there is lymph node involvement or metastasis

40. Vascular malformation : Dieulafoy’s disease This is essentially a gastric arterial venous malformation that has a characteristic histological appearance. Bleeding due to this malformation is one of the most difficult causes of upper gastrointestinal bleeding to treat. .

41. The lesion itself is covered by normal mucosa and, when not bleeding, it may be invisible. If it can be seen while bleeding, all that may be visible is profuse bleeding coming from an area of apparently normal mucosa. If this occurs, the cause is instantly recognisable. If the lesion can be identified endoscopically there are various means of dealing with it, including injection of sclerosant and endoscopic clips. If it is identified at operation then only a local excision is necessary. Occasionally , a lesion is only recognised after gastrectomy and sometimes not even then. The pathologist, as well as the endoscopist, may have difficulty in finding it.

42. Aortic enteric fistula This diagnosis should be considered in any patient with haematemesis and melaena that cannot be otherwise explained.

43. Aortic enteric fistula Contrary to expectation, the bleeding from such patients is not always massive, although it can be. Very often there is nothing much to distinguish between the bleeding from the aortic enteric fistula and any other recurrent upper gastrointestinal bleeding.The vast majority of patients will have had an aortic graft and, in the absence of this, the diagnosis is unlikely. However , it is occasionally seen in patients with an untreated aortic aneurysm. A well-performed CT scan will commonly allow the diagnosis to be made with certainty. The condition should be managed by an expert vascular surgeon as, whether secondary or primary, the morbidity and mortality are high.

44. References : Bailey & Love’s SHORT PRACTICE of SURGERY 26th EDITION BROWSE’S INTRODUCTION TO THE SYMPTOMS & SIGNS OF SURGICAL DISEASE 5th ed Schwartz’s Principles of Surgery Tenth Edition American college of gastroenterology .Management of peptic ulceration. retrived from https://gi.org/guideline/management-of-patients-with-ulcer-bleeding / Textbook of Surgery 3 rd ed Macleod’s Clinical Diagnosis 1 st ed

45. Thank you !!