Haematemesis Differential Diagnosis PDF

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Summary

Differential diagnosis summary that will come in handy for clinical exam ISCE in fourth year....

Description

Haematemesis

Oesophageal

Others

Gastric

• Oesphageal varices (2⁰ portal HTN) • Oesophagitis

• Ingestion of corrosives

• Gastric/duodenal ulcer • Gastritis - NSAIDs/aspirin/alcohol

• Mallory-Weiss tear

• AV malformation • False haematemesis - nose bleed, haemoptysis

• Gastric carcinoma

• Oesophageal cancer

• Trauma - foreign body

HAEMATEMESIS DIFFERENTIAL DIAGNOSIS Condition

Symptoms

Oesophageal varices

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Risk factors: Decompensated liver (cirrhosis/hepatitis) Malnourishment Alcohol intake Aspirin, NSAIDs Infections Compression – tumour

• • • •

Haematemesis +/malaena Abdo pain Features of liver disease Dysphagia Confusion – encephalopathy

Signs •

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Peripheral shut down - ↑CRT, pallor, cold Shock - ↑HR, ↓BP ↓ urine output Signs of chronic liver disease ↓GCS, septic

Investigations

Acute • 2 wide bore cannulas - Fluid resuscitation, risk assessment (Rockall score), ITU/HDU • Monitor BP, HR, urine output • Major haemorrhage protocol – >30% loss - transfusion, FFP/Plt, Vit K/PCC (warfarin) • Terlipressin – suspected variceal bleed, stop after definitive haemostasis is achieved • Prophylactic ABx - confirmed bleed, thiamine if alcoholic, treat encephalopathy • Balloon tamponade – consider as temporary salvage treatment for uncontrolled • Endoscopy Band ligation (within 4hr)/Emergency sclerotherapy or TIPS – Transjugular intrahepatic portosystemic shunts Prevention • Education, lifestyle – smoking, alcohol, diet • Propanolol – reduce rebleeding and mortality • Endoscopic variceal band ligation (EVL) – PPI cover to prevent EVL-induced ulcers

• • •

FBC, coag, U+E, LFT, G+S, crossmatch 6 units OGD endoscopy - diagnostic Cardiac enzyme, ECG CXR, AXR, MRI, CT

Acute • 2 wide bore cannulas - Fluid resuscitation, risk assessment (Rockall score), ITU/HDU • Major haemorrhage protocol - >30% loss - transfusion, FFP/Plt, Vit K/PCC (warfarin) • Endoscopy if still bleeding – banding/clipping/thermocoag/adrenaline injection Prevention • Address precipitating factors – binge drinking, alcohol consumption, excessive straining/lifting, violent coughing

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FBC, U+E, LFT, glucose, CRP Urgent endoscopy + biopsy CXR – mets Barium swallow CT/MRI – thorax and abdo FDG-PET – staging

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OESOPHAGEAL

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Mallory-Weiss tear Excessive alcohol Retching due to gastroenteritis, chronic cough, hiatus hernia, bulimia

Oesophageal cancer Adenocarcinoma SCC RFs – Barrett’s Stricture/achalasia

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•

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Haematemesis following a bout of retching/vomiting Malaena, dizziness, light-headedness, syncope, abdo pain

• •

No specific signs Rockall score – assess degree of blood loss

Dysphagia (food sticking), vomiting Anorexia, weight loss Haematemesis, malaena Hoarseness, persistent cough Retrosternal pain Lymphadenopathy

Management

FBC ↓Hb, ↓Plt, ↑WBC Coag – INR, coagulopathy U+E (↑urea), LFT, glucose G+S, crossmatch 6 units CXR – aspiration/infection OGD endoscopy Ascitic tap – bacterial peritonitis AXR, USS +/- doppler (portal veins) CT, MRI, elasticity measurement (liver fibrosis)

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ABx and antithrombotic prophylaxis Endoscopic mucosal resection – early cancer Endoscopy + photodynamic therapy/lasers/radiofrequency ablation Endoscopic resection for more advanced cases – unfit for surgery Endoscopic oesophagectomy – treatment of choice for most advanced cancers Chemoradiotherapy Palliative – radiotherapy/chemo/brachytherapy, stenting – swallowing, PEG tube

Bleeding peptic/duodenal ulcer

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haematemesis, malaena, coffee ground vomit

• • •

GASTRIC

• • Gastritis H.pylori NSAIDs, aspirin Stressful event – major surgery, bad injury, critical illness ↑Alcohol

• • • •

Gastric carcinoma

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H. pylori Diet – high salt/preservative Smoking Obesity FHx

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Duodenal – epigastric pain relieved by eating Peptic – pain worsened by eating Night time waking Relieved by food, antacid Bloating, distention Perforation – sudden onset sharp pain Dyspepsia, bloating Epigastric pain N+V, early satiety Haematemesis/ coffee ground vomit

•

Non-specific dyspepsia, dysphagia Weight loss, anorexia Chronic GI bleed Anaemia Abdo pain

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• •

Epigastric tenderness May have signs of peritonitis ↓BP Cool extremities Dehydration (sunken eyes, dry mucosa) Tender epigastric Signs of blood loss, dehydration

Epigastric mass Hepatomegaly Jaundice Ascites Troisier’s sign – Virchow’s node

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Bloods – FBC (↓Fe anaemia), G+S, crossmatch (bleeding), coag, LFT, U+E ↑urea, Ca Carbon13 urea breath test OGD + biopsy + pH study Barium swallow, eAXR

Acute • 2 wide bore cannulas - Fluid resuscitation, risk assessment (Rockall score), ITU/HDU • Major haemorrhage protocol - >30% loss - transfusion, FFP/Plt, Vit K/PCC (warfarin) • Endoscopy clipping/thermal coagulation or Surgical laparotomy/laparoscopic General • Education, modify RFs – stop medication such as NSAIDs, alendronate, stop smoking, alcohol intake, healthy diet, smaller meals, exercises Medical • H. Pylori eradication Rx – 1/52 course PPI + Amox 1g + Clarithromycin 500mg/Metronidazole 400mg – all 3 given BD • PPI, H2 receptor antagonist General • Education, lifestyle and diet changes – smaller, frequent meals, avoid irritating food (spicy, acidic, fried, fatty), stop alcohol, stop smoking, reduce stress • Stop causative medications – NSAIDs, aspirin Medical • Antacids, H2 antagonist, PPI, treat H.pylori if +

FBC, LFT, U+E, CRP, glucose Rapid-access flexible endoscopy + biopsy – IOC CT thorax + abdo Barium swallow – filling defect in the cardia of stomach

• Nutritional deficiency – support, analgesia, nausea, constipation, depression Surgery – treatment of choice • Distal (antral) – subtotal gastrectomy; proximal – total gastrectomy • Lymphadenectomy if curable cancer • Perioperative combination chemotherapy Palliative • Palliative chemotherapy, endoscopic laser therapy, stenting

Bloods – FBC (↓Fe anaemia), G+S, crossmatch 6 units, coag, LFT, U+E ↑urea, Ca Carbon13 urea breath test/ stool antigen – H. Pylori OGD – urgent Erect XR – perforation CT abdo, USS abdo...