A 35-year-old woman vomiting blood

Published on 10/04/2015 by admin

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Last modified 10/04/2015

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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

White cell count: 10.1 × 109/L
Haemoglobin: 11.8 g/dL
Platelets: 78 × 109/L
Prothrombin time 17.6 seconds
Sodium: 131 mmol/L
Potassium: 3.8 mmol/L
Bicarbonate: 12 mmol/L
Urea: 18.7 mmol/L
Creatinine: 54 mmol/L
Albumin: 32 g/L
ALP: 114 U/L
Bilirubin: 23 mmol/L
AST: 63 U/L
ALT: 47 U/L
GGT: 61 U/L

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.

image

Figure 35.1A,B

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).

image

Figure 35.2

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