An Approach to Haematemesis and Melena

Introduction
Differential Diagnosis  
Evaluation Priorities
Resuscitation and Initial Management

Context: Emergency Unit

Introduction

Haematemesis almost always implies that the bleeding source is in the foregut, above the ligament of Treitz, originating from the duodenum, stomach or oesophagus.

Some of this blood will be vomited, and some will transit through the gut, and eventually exit as a dark, sticky, black stool: the characteristic appearance of melena. Some patients never vomit at all, and just present with melena, or if the bleeding is of high volume, even with fresh, unaltered blood per rectum.

Occasionally a patient will vomit blood that has accumulated in the stomach from a non-GI source- either from severe epistaxis or haemoptysis these are usually clinically obvious.

Bleeding from the small bowel is extremely rare and will present with melena or fresh bleeding PR, and will not regurgitate back into the stomach, against persistalsis, to be vomited out.

Differential Diagnosis

Evaluation Priorities

• How bad is this going to be? (severity scoring)- the modified Blatchford score is the most validated way of determining the severity of bleeding before any endoscopy assessment is done. This will assist in deciding which patients need immediate endoscopy, versus who can wait until the following day.
• The appearance of the ulcer at endoscopy predicts the risk of rebleeding and thus helps to guide the need to intervene endoscopically.
• Rockall score- is an overall score that includes both clinical presentation AND endoscopic diagnosis- this help predict the overall outcome, but it can only be calculated AFTER the endoscopy is performed.
• Is this a variceal bleed or not?
• Patients with known liver disease (cirrhosis/ alcoholic/ hepatitis) or with clinical signs of liver disease are assumed to be bleeding from portal hypertension and oesophageal varices. However up to 1/3 of patients with known oesophageal varices bleed from other causes, such as peptic ulcers or gastritis, so they must ALWAYS have an endoscopy.

Resusitation and Initial Management
Transfuse patients with massive bleeding with blood, platelets and clotting factors in line with local protocols for managing massive bleeding.

Endoscopy
Endoscopy is the primary diagnostic investigation in patients with acute upper gastrointestinal bleeding. Endoscopy aids diagnosis yields information that helps to predict outcome and most importantly allows treatments to be delivered that can stop bleeding reduce the need for transfusion and reduce the risk of re-bleeding and the length of hospital stay. It allows risk assessment for both variceal and non-variceal haemorrhage and who is eligible for endotheraphy.
(See Ulcer risk stratification Forrest Classification with the Blatchford score)

Timing of Endoscopy

• Patients who remain unstable should be evaluated in theatre with airway protection
• The vast majority of patients will stabilise with resuscitation
• Those with a high Blatchford score > 8 should have endoscopy urgently, ideally within 6 -12 hours
• The others should have endoscopy within 24 hours of admission; they should not wait the whole weekend

Endotherapy
The bleeding source should be treated endoscopically.
Dual therapy with Injection 1/10000 adrenalin + heater probe or Endoscopic clip is best.
Varices should be treated by banding.
The appearance of the ulcer at endoscopy predicts the risk of rebleeding and thus helps to guide the need to intervene endoscopically.