A 35-year-old woman vomiting blood

Published on 10/04/2015 by admin

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Problem 35 A 35-year-old woman vomiting blood

Jonathan Mitchell

It is 7 p.m. on a busy Saturday night. You are called urgently to the emergency department. A 35-year-old woman has been brought in by her husband. She has vomited bright red blood on three occasions over the last 2 hours. The last episode was on arrival in the resuscitation room. The nurses say it was around 500 mL. She is pale but conscious with a GCS of 15. Her pulse is 120 and her blood pressure is 96/57 mmHg. She has an oxygen saturation of 94% on room air.

Q.1

What are your immediate priorities?

Q.2

What further elements of the history would you like from the woman and her partner?

Blood tests become available as follows:

Investigation 35.1 Summary of results

Q.3

What do these results tell you? What would you like to organize next?

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.

Q.4

Does this information change your immediate management?

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.

Q.5

What abnormality do these images show? What options are available to the endoscopist?

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

Q.6

Is any other treatment appropriate at this stage?

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.

Q.7

What may be happening and why? How can you manage the situation?

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.

Q.8

What are you going to do?

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

Q.9

What procedure has been performed? What are the potential risks of this procedure?

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.

Answers

A.1 The patient has had a significant upper GI bleed with a very large witnessed haematemesis. Despite her young age, she is already showing signs of shock with a tachycardia. Her airway may be at risk if she vomits further. High-flow oxygen should be administered. Intravenous access with two large-bore cannulae should be secured. Blood should be taken immediately for a 6 unit cross-match, full blood count, clotting, electrolytes and liver enzymes. Intravenous fluids can be used to restore circulating volumes although note cautions later. There are many debates about the best fluids to use (crystalloid vs colloid) but there is no doubt that the best of all in this situation is blood.

A.2 You will want to know any previous medical history including previous GI bleeding, peptic ulceration or liver disease. Has this happened before? Has it been accompanied by abdominal pain or dyspepsia, suggestive of a peptic cause? Did she have ‘normal’ vomitus before bringing up blood? This may suggest a Mallory–Weiss tear following trauma to the oesophageal mucosa. This can produce surprisingly brisk haemorrhage. Does she take any culpable medications including often short courses of non-steroidals or aspirin. Has she had melaena? The absence of melaena in the context of a large haematemesis normally implies an oesophageal source.

A.3 She has a very mild anaemia. This is often overtly reassuring but remember! In the acute stages of any form of bleeding the haemoglobin concentration is initially well maintained until haemodilution occurs. Haemoglobin concentration is not the same as total haemoglobin so do not be falsely reassured. Her platelet count is very low. While there are many causes, it may signify hypersplenism and, therefore, portal hypertension and liver disease.

There is further evidence of this in her liver synthetic function. She has a slightly increased prothrombin time and a mildly depressed albumin. In addition she has minor abnormality of her liver enzymes.

The urea : creatinine ratio is helpful in ascertaining the source of any GI bleed. In this case, we know from her presentation that it is upper GI. However, in cases of melaena or passage of fresher blood rectally, this ratio can be helpful. The sudden appearance of a high protein load in the upper gut generates a high level of blood urea in upper GI blood loss. Later, this becomes relevant in this case.

The woman needs an endoscopy urgently. In view of the possibility of variceal haemorrhage, the patient is likely to need a general anaesthetic for airway protection. You may want to consider platelet transfusion.

A.4 This information makes the presence of significant liver disease and, therefore, a variceal bleed, all the more likely. Variceal bleeding is an endoscopic emergency. You may even want to consider giving a potent vasoconstrictor such as terlipressin if endoscopy is likely to be delayed. Get advice now. Antibiotics may need to be considered. Beware over-zealous volume resuscitation. (See later to find out why.)

A.5 These are endoscopic images of the lower oesophagus: four variceal cords are seen. There are several ‘red spots’ which are signs of high-risk bleeding points although no active bleeding is currently seen. The endoscopist rightly asserts that the bleeding has come from the varices and places bands on the varices endoscopically. There is good evidence that this technique is significantly superior to older ‘injection’ sclerotherapy.

A.6 In variceal bleeding, broad-spectrum antibiotics reduce septic complications and short-term mortality. If bleeding has not been reliably controlled, terlipressin may be required but this drug is a potent vasoconstrictor and can cause ischaemic complications if not used with care. She is now at risk of hepatic decompensation.

A.7 First consider the possible latent effects of sedative or anaesthetic agents especially in a patient with liver disease in whom these drugs are often metabolized extremely slowly. However, she has emptied a large ‘high protein load’ into her gut – i.e. blood. This provides a substrate for gut bacteria to produce ammonia.

Ammonia, and associated by-products of protein metabolism, may enter the systemic circulation via the portosystemic shunts, of which her varices are examples, which define portal hypertension. In addition, poor synthetic function means that ammonia entering the liver via the portal circulation will not be adequately metabolized. This then causes hepatic encephalopathy.

Hepatic encephalopathy may have been precipitated by drugs, as above, or signify further bleeding. A patient in this situation is at risk of losing airway control. Further sedatives are not appropriate outside a high dependency/intensive care environment. Aperients such as lactulose may be useful later on.

A.8 The situation has deteriorated significantly and she is now in grave danger. She needs to be intubated and taken to ITU as soon as possible. If not already given, a vasoconstrictor such as terlipressin should be administered.

It is quite likely that over-enthusiastic fluid resuscitation has led to a rise in her portal pressure to provoke further bleeding. Once stabilized, she will need a further endoscopy.

A.9 This is a transjugular portosystemic shunt stent or TIPSS. The metallic stent is seen lying between the hepatic veins and portal vein in an artificially created channel. The radiologist has also inserted some metallic coils into one of the collateral vessels feeding her bleeding varices.

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.

Issues to Consider

• Using the information above and your knowledge of physiology, what major complication might follow TIPSS insertion?

• What class of medication has been shown to reduce the risk of variceal haemorrhage in the long term and why is choice of drug important?

• What are the Blatchford and Rockall scores? Would they have been useful here?

Further Information

, http://www.patient.co.uk/doctor/Upper-Gastrointestinal-Bleeding.htm. A decent article on upper GI bleeding with a useful ‘calculator’

, www.daveproject.org. An excellent online source of fascinating endoscopy videos

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