[level-membership-for-surgery-category]

Problem 35 A 35-year-old woman vomiting blood

Blood tests become available as follows:

Investigation 35.1 Summary of results

A further detailed history reveals that the woman has never vomited blood before but did have one episode of black stools 3 weeks earlier which she put down to diet. She has had no indigestion and has not taken any non-steroidal anti-inflammatories. She has never had any operations. Her partner volunteers that, up until 3 years ago, she had had longstanding problems with alcohol excess and had seen a hospital specialist who had warned her that she would die if she continued to drink. They had made a decision to move across the country to start a new life and she had not had an alcoholic drink since.

You organize an urgent endoscopy. The endoscopist finds a large amount of fresh and altered blood in the stomach. No bleeding source is identified in the stomach or the duodenum. Figure 35.1A, B shows the positive findings.

Figure 35.1A,B

The endoscopist places four bands on the varices, with apparent haemostasis. She returns to the ward. It is now 11 p.m.

At 5 a.m. you are called to the ward. The woman has had no further haematemesis. She has become confused and is trying to remove intravenous cannulae and get out of her bed. Her blood pressure is 120/79 mmHg, her pulse 90 and her SpO₂ 98% on room air. She has had 3 units of FFP. A fourth unit of packed cells is running.

Shortly after your arrival, she has a further large haematemesis. Her GCS is 11. Her pulse has risen to 130 and her blood pressure fallen to 86/49 mmHg. She is sweaty and peripherally cool. The nurses and her husband are very concerned and look to you for answers.

The woman is taken to the endoscopy suite once more. Copious fresh blood is seen in the oesophagus. Despite their best efforts, haemostasis cannot be achieved. A balloon tamponade tube is inserted with airway control. The patient is taken to the intensive care unit.

The following morning a definitive procedure is performed. An image taken from this procedure is shown (Figure 35.2).

Figure 35.2

Three days later the woman is discharged. Two years later, she remains well. She works full time as a chef and has had no further bleeding.

Revision Points

Management of Variceal Haemorrhage

Airway and Breathing

• Patients with variceal bleeding are at high risk of compromising their airway.

• Involve ITU early. All patients requiring endoscopy for actively bleeding varices will need to be intubated.

• Bleeding is often complicated by encephalopathy. Think aspiration!

Resuscitation

• Resuscitation is paramount.

• Two large-bore peripheral cannulae, blood for FBC, clotting and 6 unit cross-match.

• Blood is the best colloid! Consider group-specific or O neg blood.

• Avoid over-filling! This raises portal pressure and can promote further bleeding. Aim for a systolic BP of 100, a pulse of <100 and a CVP of 6–10.

• Consider platelets if <50. There is no evidence that the use of FFP is beneficial. Conversely, its use may raise portal pressure and promote bleeding.

Vasoconstrictors

• In patients with active suspected variceal bleeding, give a 2 mg IV bolus of terlipressin.

• Post endoscopy, terlipressin should be continued at 1–2 mg IV qds for a maximum of 72 hours. This can be shortened further if adequate haemostasis is achieved at endoscopy.

• Watch out for ischaemic complications in long-term use.

Endoscopy

• Involve the on-call endoscopist early. Variceal haemorrhage is an endoscopic emergency.

• Endoscopic band ligation (EBL) is the treatment of choice but alternatives in skilled hands include tissue or ‘super’ glue sclerotherapy, especially in non-oesophageal varices where band ligation is not an option. Older sclerotherapeutic agents such as ethanolamine are no longer used.

Antibiotics

• All patients with a confirmed variceal haemorrhage must receive parenteral broad-spectrum antibiotics.

• There is excellent evidence that this prevents the late septic complications which lead to renal failure, hepatic decompensation and death. There is even evidence that sepsis, for example from spontaneous bacterial peritonitis in a patient with ascites, may be the trigger that leads to increased portal blood flow and bleeding in the first place.

Balloon Tamponade

• ‘Sengstaken’ or ‘Minnesota’ tubes (Figure 35.3) can be life-saving but in inexperienced hands may be extremely dangerous and should always be placed by experienced operators in an intubated patient.

• With improved access to endoscopy and improved endoscopic techniques as well as the availability of TIPSS, they are required less and less.

Figure 35.3

Further Management

• The majority of patients will need to be managed on HDU/ITU immediately post endoscopy.

• The majority of deaths occur from the complications of bleeding including liver decompensation, encephalopathy, sepsis and renal failure.

• Stable patients normally require a repeat endoscopy within 48–72 hours. In those in whom endoscopy fails and in patients with non-oesophageal varices (e.g. gastric, duodenal), TIPSS is the treatment of choice and is being used earlier than ever before.

[/level-membership-for-surgery-category][not-level-membership-for-surgery-category]

Problem 35 A 35-year-old woman vomiting blood

Blood tests become available as follows:

Investigation 35.1 Summary of results

A further detailed history reveals that the woman has never vomited blood before but did have one episode of black stools 3 weeks earlier which she put down to diet. She has had no indigestion and has not taken any non-steroidal anti-inflammatories. She has never had any operations. Her partner volunteers that, up until 3 years ago, she had had longstanding problems with alcohol excess and had seen a hospital specialist who had warned her that she would die if she continued to drink. They had made a decision to move across the country to start a new life and she had not had an alcoholic drink since.

You organize an urgent endoscopy. The endoscopist finds a large amount of fresh and altered blood in the stomach. No bleeding source is identified in the stomach or the duodenum. Figure 35.1A, B shows the positive findings.

Figure 35.1A,B

The endoscopist places four bands on the varices, with apparent haemostasis. She returns to the ward. It is now 11 p.m.

At 5 a.m. you are called to the ward. The woman has had no further haematemesis. She has become confused and is trying to remove intravenous cannulae and get out of her bed. Her blood pressure is 120/79 mmHg, her pulse 90 and her SpO₂ 98% on room air. She has had 3 units of FFP. A fourth unit of packed cells is running.

Shortly after your arrival, she has a further large haematemesis. Her GCS is 11. Her pulse has risen to 130 and her blood pressure fallen to 86/49 mmHg. She is sweaty and peripherally cool. The nurses and her husband are very concerned and look to you for answers.

The woman is taken to the endoscopy suite once more. Copious fresh blood is seen in the oesophagus. Despite their best efforts, haemostasis cannot be achieved. A balloon tamponade tube is inserted with airway control. The patient is taken to the intensive care unit.

The following morning a definitive procedure is performed. An image taken from this procedure is shown (Figure 35.2).

Figure 35.2

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Clinical Problems in Medicine and Surgery