Massive Haematemesis in a 60-Year-Old Man: Emergency Investigations and Management

Causes (at this age)

Immediate Priorities: ABC + Resuscitation

Airway

• If haematemesis is massive or the patient is encephalopathic, protect the airway - consider early endotracheal intubation before endoscopy to prevent aspiration.

Circulation - Resuscitation

1. Two large-bore IV cannulae (14-16G) peripherally; for severe bleeding add a central venous pressure line
2. Urinary catheter for urine output monitoring
3. Fluid resuscitation - start with crystalloid, but transfuse blood as soon as available; transfuse when >30% of blood volume has been lost
4. Blood products: Correct coagulopathy (most common causes: liver disease, anticoagulation therapy) with fresh-frozen plasma or concentrated clotting factors; vitamin K 10 mg IV if liver disease suspected
5. Platelets: Transfuse if count <50 × 10⁹/L (thrombocytopenia from hypersplenism in cirrhosis)
6. Avoid hypervolaemia in variceal bleeding - it increases portal pressure and exacerbates bleeding

Emergency Investigations

Bloods (send immediately)

Point-of-Care

• Bedside ultrasound (FAST/POCUS): Ascites, splenomegaly, portal hypertension signs

Risk Stratification: Rockall Score

• A pre-endoscopy score ≥3 warrants urgent endoscopy and high-dependency care
• A Blatchford score of 0 (or ≤1) may identify patients safe for outpatient management, but NOT applicable here

Management

Step 1: Pharmacological (start immediately, before endoscopy)

• IV PPI (e.g., omeprazole 80 mg bolus then 8 mg/h infusion) - reduces rebleeding after endoscopy; no proven benefit prior to endoscopy but commonly given
• Tranexamic acid - meta-analysis data suggests may reduce overall mortality (fibrinolysis inhibition)

• Terlipressin 2 mg IV 6-hourly (splanchnic vasoconstrictor - first-line) - reduces portal pressure
• Alternatively: Octreotide or somatostatin infusion
• Prophylactic antibiotics (e.g., IV ceftriaxone 1 g/day) - reduces infection risk, improves survival in cirrhotic patients with variceal bleeding

Step 2: Emergency Endoscopy (OGD)

• For severe bleeding: carry out immediately after haemodynamic stabilisation
• For mild/moderate bleeding: may defer to next morning, guided by local protocol
• Do NOT delay surgery waiting for endoscopy if bleeding persists

• Combination therapy: Adrenaline (epinephrine) injection + heater probe/clips achieves haemostasis in ~70%
• Endoscopic clips (haemoclips) alone or combined
• Forrest classification guides intervention:
  • Ia (spurting) / Ib (oozing): endoscopic therapy mandatory
  • IIa (visible vessel) / IIb (adherent clot): endoscopic therapy recommended
  • IIc / III (flat pigmented spot/clean base): medical management, safe discharge

• Oesophageal varices: Band ligation preferred over sclerotherapy (lower rebleeding rate); sclerotherapy if bleeding is too profuse for ligation
• Gastric (fundal) varices: Cyanoacrylate glue injection or thrombin injection

Step 3: When Endoscopy Fails

• Interventional radiology - transcatheter embolisation (angiography): valuable alternative to surgery for unidentified source or rebleeding after endoscopy; low ischaemia risk due to rich gastroduodenal collateral supply
• Surgery: Indicated if bleeding persists or >6 units of blood required
  • Frail/elderly patients paradoxically need earlier surgery (higher risk of death from continued bleeding)
  • At laparotomy: duodenotomy + underrunning of gastroduodenal artery for duodenal ulcer; partial gastrectomy for gastric ulcer

• Balloon tamponade (Sengstaken-Blakemore tube or Minnesota tube): emergency bridge when rate of blood loss prohibits endoscopy
  • Gastric balloon inflated with 300 mL air, retracted to fundus; oesophageal balloon inflated to 60 mmHg
  • Maximum 24 hours (risk of oesophageal pressure necrosis)
  • Self-expanding covered metal oesophageal stents are an equivalent modern alternative
• TIPSS (Transjugular Intrahepatic Portosystemic Stent Shunt): when pharmacological + endoscopic therapy have failed; now the preferred method for refractory portal hypertension; inserted under local anaesthetic via internal jugular vein under fluoroscopic/USS guidance

Variceal Bleeding Management Flowchart

Ongoing Monitoring

• Hourly urine output (target >0.5 mL/kg/hr)
• Serial Hb every 4-6 hours in active bleeding
• CVP monitoring in severe cases
• Coagulation profile - recheck after FFP administration
• Watch for rebleeding - in peptic ulcer: visible vessel at endoscopy, large ulcer >2 cm, vessel >2 mm diameter, and prior ulcer bleeding are independent predictors of endoscopic therapy failure (per Forrest classification data from Maingot's Abdominal Operations)
• Ward level: HDU/ITU for all cases of massive haematemesis

Key Points for a 60-Year-Old

• Age 60 scores 1 on the Rockall scale (60-79 years category) - already elevated risk
• NSAID use is a major predisposing factor at this age and should be stopped
• Comorbidities (IHD, renal impairment) shift Rockall score toward 2-3 and influence surgical fitness
• Frail or elderly patients with continued bleeding should proceed to surgery earlier, not later
• If liver disease is present, encephalopathy risk is real - consider early intubation