2 episodes of haemetemeis
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"upper gastrointestinal bleeding" AND management
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Here is a comprehensive clinical overview of haematemesis with two episodes:
Haematemesis - Clinical Overview
Haematemesis is the vomiting of blood, indicating an upper gastrointestinal (UGI) haemorrhage - i.e., a source proximal to the ligament of Treitz. Two episodes indicate active or recurrent bleeding requiring urgent evaluation.
Epidemiology
- Incidence: over 100 per 100,000/year in Western populations; increases with age
- In-hospital mortality: 5-10% overall; rises to 33% when bleeding is first observed in already-hospitalised patients
- Bleeding is self-limited in ~80% of patients; in the remaining 20% who continue to bleed or rebleed, mortality rises to 30-40%
- Strong association with NSAID use
Causes of Upper GI Bleeding
| Condition | Frequency (%) |
|---|---|
| Peptic ulcers (total) | ~40-60% |
| - Duodenal ulcer | 33 |
| - Gastric ulcer | 21 |
| - Oesophageal ulcer | 6 |
| Erosions (oesophageal, gastric, duodenal) | 26 |
| Oesophageal varices | 4-22% |
| Mallory-Weiss tear | 4 |
| Dieulafoy lesion | 3 |
| Tumour / Neoplasm | ~3 |
| Vascular lesions / Angioectasia | ~4 |
| No cause found | ~7 |
Bailey & Love's Short Practice of Surgery, p.1187; Sleisenger & Fordtran's GI and Liver Disease
Initial Assessment and Resuscitation
ABC approach first:
- IV access - large-bore x2; for severe bleeding add central venous pressure monitoring
- Urinary catheterisation - monitor urine output in haemodynamic compromise
- Cross-match blood - transfuse when >30% blood volume lost; use restrictive strategy (Hb threshold ~7-8 g/dL)
- Correct coagulopathy - especially in liver disease or anticoagulation therapy; use fresh-frozen plasma or concentrated clotting factors with haematology input
- NG lavage - red blood or coffee-ground aspirate confirms UGI source and aids endoscopy prep
- BUN:creatinine ratio - elevated ratio suggests UGI bleeding (digested blood raises BUN)
Note: There is no evidence for IV PPI administration prior to endoscopy to reduce rebleeding or mortality.
Risk Stratification
Glasgow-Blatchford Score (GBS) - Pre-endoscopy
Uses: BUN, Hb, systolic BP, HR, syncope, melaena, liver disease, heart failure
- GBS = 0: suitable for outpatient management
- GBS ≥ 6: ~50% likelihood of requiring intervention
Rockall Score - Pre- and Post-endoscopy
| Variable | Score 0 | Score 1 | Score 2 | Score 3 |
|---|---|---|---|---|
| Age | <60 | 60-79 | >80 | - |
| Shock | Pulse <100, BP >100 | Pulse >100 or BP <100 | Pulse >100, BP <100 | - |
| Comorbidities | None | - | CCF/CAD | Renal/liver failure, malignancy |
| Endoscopic signs | None/dark spot | - | Blood/clot/visible vessel | - |
| Diagnosis | Mallory-Weiss/no lesion | All others | UGI malignancy | - |
- Score 0-1: 0% mortality
- Score 5: ~10% mortality
- Score 8+: ~40% mortality
Bailey & Love's Short Practice of Surgery, p.1188; Current Surgical Therapy 14e
Investigation
- Upper GI endoscopy (EGD) is the investigation of choice
- Should be performed within 24 hours in most patients after haemodynamic resuscitation
- Immediately in severe/ongoing bleeding
- Consider prophylactic endotracheal intubation if active bleeding is severe (aspiration risk)
- Prokinetic (erythromycin or metoclopramide) before endoscopy improves visualisation by clearing blood
Treatment
Endoscopic (first-line)
Achieves haemostasis in approximately 70% of cases. Best evidence supports:
- Combination of adrenaline (epinephrine) injection + heater probe and/or clips
- Other methods: band ligation (varices), argon plasma coagulation, electrocoagulation, laser photocoagulation
- If rebleeding after first endoscopy: repeat endoscopic treatment before escalating
Medical
- PPI (proton pump inhibitor) after endoscopy reduces rebleeding risk
- Tranexamic acid (anti-fibrinolytic) - meta-analysis suggests possible reduction in overall mortality (recent 2025 systematic review [PMID: 40029534] confirms utility for acute GI bleeding)
- H2 antagonists: commonly used adjunct
Angiographic Embolisation
- Used when bleeding source cannot be identified endoscopically or after failed endoscopic treatment
- Low risk of ischaemia due to rich collateral supply of stomach and duodenum
- Rescue surgery after failed embolisation carries poor outcome
Surgical Treatment
Indicated when:
- Persistent or recurrent haemodynamic instability
- Transfusion requirement >6 units red cells
- Visible/spurting vessel or clot in ulcer base at endoscopy
- Frail/elderly patients should have earlier surgical intervention (paradoxically, higher operative risk if delayed)
Surgical options for bleeding peptic ulcer: oversewing alone; oversewing + vagotomy and drainage; vagotomy and antrectomy. Data suggest vagotomy + drainage has lower 30-day mortality (12%) vs. resection (23%) or oversewing alone (27%).
Special Considerations
- Variceal bleeding: suspected in cirrhosis/portal hypertension; managed with band ligation + octreotide/terlipressin + prophylactic antibiotics (norfloxacin/ceftriaxone); TIPS if refractory
- Mallory-Weiss tear: after forceful retching/vomiting; usually self-limiting; endoscopic treatment if persistent
- Coagulopathy: anticoagulation therapy and liver disease are the most important current causes; correct before/alongside endoscopy
Sources: Bailey & Love's Short Practice of Surgery 28th Ed.; Sleisenger & Fordtran's Gastrointestinal and Liver Disease; Current Surgical Therapy 14e; Frameworks for Internal Medicine. Recent evidence: Tranexamic acid in GI bleeding (2025 meta-analysis) | Endoscopic vs. medical management of peptic ulcers with adherent clots (2024 meta-analysis)
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