HAEMATEMESIS & MELAENA Seminar Prepared by: Mohammed Musa Mohammed Saadi Safa Sami Surgery College of Medicine - University of Kirkuk

1. HAEMATEMESIS
& MELAENA

2. Haematemesis is the vomiting of blood
from the upper GI tract.
Bright red blood or clots imply active bleeding and are a
medical emergency. Altered blood with a dark, granular
appearance (‘coffee-grounds’) suggests that bleeding
has ceased or has been relatively modest .This must be
differentiated from haemoptysis when the blood is
coughed up.

3. Melaena refers to the black, tarry stool
produced in the presence of upper
gastrointestinal haemorrhage.
The black appearance of the stool is caused
by oxidation of iron in the haemoglobin as it
passes through the ileum and colon.

4. Incidence:
●Upper gastrointestinal haemorrhage remains a major medical problem
with an incidence of over 100/100 000 per year in Western practice that
increases with increasing age .
●Haemorrhage is strongly associated with NSAID use .
●Despite improvements in diagnosis and the proliferation in treatment
modalities over the last few decades, an in-hospital mortality of 5–10 per
cent can be expected. This rises to 33 per cent when bleeding is first
observed in patients who are hospitalised for other reasons.

5. Presentation:
●Haematemesis with or without melaena.
●There may be associated symptoms of lethargy, dizziness,
shortness of breath, abdominal or retrosternal pain.
●There may be signs of hypovolaemic shock.

6. Causes of upper gastrointestinal bleeding:

7. Emergency Management
Whatever the cause, the principles
of management are identical. First,
the patient should be adequately
resuscitated and, following this, the
patient should be investigated
urgently to determine the cause of
the bleeding. Only then should
treatment of a definitive nature be
instituted.

8. •For any significant gastrointestinal bleed, intravenous access should be
established and, for those with severe bleeding, central venous pressure
monitoring should be set up and bladder catheterisation performed.
•Blood should be cross-matched and the patient transfused as clinically
indicated, usually when >30 per cent of blood volume has been lost .
•There is no evidence for the use of intravenous proton pump inhibitors
prior to endoscopy .
•As a general rule, most gastrointestinal bleeding will stop, albeit
temporarily, but there are sometimes instances when this is not the
case. In these circumstances, resuscitation, diagnosis and treatment
should be carried out simultaneously.

9. There are occasions when life saving manoeuvres have
to be undertaken without the benefit of an absolute
diagnosis
●For instance, in patients with known oesophageal varices and uncontrollable
bleeding, a Sengstaken –Blakemore tube may be inserted before an endoscopy
has been carried out. This practice is not to be encouraged, except in extremis .
●In some patients, bleeding is secondary to a coagulopathy. The most important
current causes of this are liver disease and inadequately controlled warfarin
therapy. In these circumstances the coagulopathy should be corrected, if possible,
with fresh-frozen plasma or concentrated clotting factors.

11. Initial assessment and risk stratification:
●Hemodynamic status should be assessed immediately upon presentation
and resuscitative measures begun as needed.
●Blood transfusions should target hemoglobin >= 7 g/dl, with higher
hemoglobins targeted in patients with clinical evidence of intravascular
volume depletion or comorbidities, such as coronary artery disease.
●Risk assessment should be performed to stratify patients into
higher and lower risk categories and may assist in initial decisions
such as timing of endoscopy, time of discharge, and level of care.

12. ●Discharge from the emergency
department without inpatient
endoscopy may be considered in patients
with:
urea nitrogen < 18.2 mg/dl;
hemoglobin >= 13.0 g/dl for men (12.0 g/dl
for women),
systolic blood pressure >= 110 mm Hg;
pulse < 100 beats / min; and absence of
melena, syncope, cardiac failure, and liver
disease, as they have < 1% chance of
requiring intervention.

13. After Stabilization
●Upper gastrointestinal endoscopy should be carried out by an
experienced operator as soon as practicable after the patient has
been stabilised.
●In patients in whom the bleeding is relatively mild, endoscopy may
be carried out on the morning after admission .
●In all cases of severe bleeding it should be carried out immediately.
●A number of scoring systems have been advocated for the
assessment of rebleeding and death after upper gastrointestinal
haemorrhage.

14. ●Perhaps the most useful of these is the Rockall score . This can be used in a
pre-endoscopy format to stratify patients to safe early discharge and
postendoscopy it can relatively accurately predict rebleeding and death.

15. Pre-endoscopic medical therapy
●Intravenous infusion of erythromycin (250 mg ~30 min before endoscopy) should
be considered to improve diagnostic yield and decrease the need for repeat
endoscopy. However, erythromycin has not consistently been shown to improve
clinical outcomes.
●Pre-endoscopic intravenous PPI (e.g., 80 mg bolus followed by 8 mg/h infusion)
may be considered to decrease the proportion of patients who have higher risk
stigmata of hemorrhage at endoscopy and who receive endoscopic therapy.
However, PPIs do not improve clinical outcomes such as further bleeding, surgery,
or death.
●If endoscopy will be delayed or cannot be performed, intravenous PPI is
recommended to reduce further bleeding.

16. Gastric lavage:
●Nasogastric or orogastric lavage is not required in patients with UGIB for
diagnosis, prognosis, visualization, or therapeutic effect .

17. Timing of endoscopy:
●Patients with UGIB should generally undergo endoscopy within 24 h of
admission, following resuscitative efforts to optimize hemodynamic
parameters and other medical problems.
•In patients who are hemodynamically stable and
without serious comorbidities endoscopy should be
performed as soon as possible in a non-emergent
setting to identify the substantial proportion of patients
with low-risk endoscopic findings who can be safely
discharged.

18. ●In patients with higher risk clinical features (e.g., tachycardia,
hypotension, bloody emesis or nasogastric aspirate in hospital)
endoscopy within 12 h may be considered to potentially improve clinical
outcomes.

19. Endoscopic therapy:
●Endoscopic therapy should be provided to patients with active spurting or oozing
bleeding or a non-bleeding visible vessel.
●Endoscopic therapy may be considered for patients with an adherent clot
resistant to vigorous irrigation. Benefit may be greater in patients with clinical
features potentially associated with a higher risk of rebleeding (e.g., older age,
concurrent illness, inpatient at time bleeding began).
●Endoscopic therapy should not be provided to patients who have
an ulcer with a clean base or a flat pigmented spot.

21. ●Epinephrine therapy should not
be used alone. If used, it should
be combined with a second
modality.
●Thermal therapy with bipolar
electrocoagulation or heater
probe and injection of sclerosant
(e.g., absolute alcohol) are
recommended because they
reduce further bleeding, need for
surgery, and mortality.

22. ●Clips are recommended because they appear to decrease further bleeding and
need for surgery. However, comparisons of clips vs. other therapies yield variable
results and currently used clips have not been well studied.
●For the subset of patients with
actively bleeding ulcers, thermal
therapy or epinephrine plus a second
modality may be preferred over clips
or sclerosant alone to achieve initial
hemostasis.

23. Medical therapy after endoscopy
●After successful endoscopic hemostasis, intravenous PPI therapy with 80 mg
bolus followed by 8 mg/h continuous infusion for 72 h should be given to patients
who have an ulcer with active bleeding, a non-bleeding visible vessel, or an
adherent clot.
●Patients with ulcers that have flat pigmented spots or clean bases can receive
standard PPI therapy (e.g., oral PPI once daily).

24. Repeat endoscopy
●Routine second-look endoscopy, in which repeat endoscopy is performed 24 h
after initial endoscopic hemostatic therapy, is not recommended.
●Repeat endoscopy should be performed in patients with clinical evidence of
recurrent bleeding and hemostatic therapy should be applied in those with higher
risk stigmata of hemorrhage.
●If further bleeding occurs after a second endoscopic therapeutic session, surgery
or interventional radiology with transcathether arterial embolization is generally
employed.

25. Algorithm for
management of
haematemesis and
melaena.

27. Peptic ulcer

28. Peptic ulcer
Gastric ulcer
Duodenal ulcer

30. Bleeding peptic ulcers
●The epidemiology of bleeding peptic ulcers exactly mirrors that of
perforated ulcers. In recent years, the population affected has
become much older and the bleeding is commonly associated with
the ingestion of NSAIDs .
●Diagnosis can normally be made endoscopically, although
occasionally the nature of the blood loss precludes accurately
identifying the lesion. However, the more experienced the
endoscopist, the less likely this is to be a problem.

31. Medical and minimally interventional
treatments
●Medical treatment has limited efficacy. All patients are commonly
started on either an H 2-tsinogatna,tsinogatna pmup notorp a ro
rotibihni pmup notorp fo tifeneb eht smrifnoc ecnedive tnecer dna
ypocsodne retfa gnideelber tneverp ot noitartsinimda.
●Furthermore, meta-analysis of studies suggests that tranexamic
acid, an inhibitor of fibrinolysis, may reduce overall mortality.

32. •Therapeutic endoscopy can achieve
haemostasis in approximately 70 per
cent of cases, with the best evidence
supporting a combination of adrenaline
injection with heater probe and/or clips .
•Therapeutic endoscopy will probably
never be effective in patients who are
bleeding from large vessels and with
which the majority of the mortality is
associated.

33. ●In patients where the source of bleeding cannot be identified or in those who
rebleed after endoscopy, angiography with transcatheter embolisation may offer a
valuable alternative to surgery in expert centres .
●The risk of significant ischaemia following embolisation is low because of the rich
collateral blood supply of the stomach and duodenum .After failed embolisation is
associated with poor outcome and it may be advantageous to proceed directly to
surgery.

34. Surgical treatment
●if bleeding persists, or recurs despite endoscopic intervention surgery,
should attempted
●factors which should encourage surgical intervention:
- A large vessel, visible in the ulcer base
- a major initial bleed,
- a re-bleed in hospital
- advanced age
- Patient who has required more than 6 units

35. ●The aim of the operation is to stop the bleeding
●The most common site of bleeding from a peptic ulcer is the duodenum
●the duodenum, and usually the pylorus, are opened longitudinally
●bleeding controlled by using well-placed sutures that under-run the vessel
●Pyloroplasty is then closed with interrupted sutures in a transverse direction
●Bleeding G.U same line +biopsy or excision
●Definitive acid lowering surgery is not now required
●very large ulcer eroding into a major branch of the left gastric artery may
necessitate a subtotal gastrectomy incorporating the ulcer

36. Long-term prevention of recurrent
bleeding ulcers

37. Erosive gastritis
●Destruction of the mucosa of the stomach
●Common Causes (NSAIDs, Alcohol and Stress)
●Treatment is supportive by changing the non selective
NSAIDs to selective cox 2 inhibitor and stop alcohol and
taking prophylactic antacids
●Surgical treatment is required in severe gastritis (total
gastrectomy)

38. Mallory–Weiss tear
●This is a longitudinal tear at the gastro-
oesophageal junction, which is induced by
repetitive and strenuous vomiting.
●Doubtless, many such lesions occur and
do not cause bleeding.
When it is a cause of haematemesis, the
lesion may often be missed as it can be
difficult to see as it is just below the
gastrooesophageal junction, a position that
can be difficult for the inexperienced
endoscopist .

39. ●Occasionally, these lesions continue to bleed and require surgical treatment.
Often the situation arises in which the surgeon does not have guidance from the
endoscopists as regards the site of bleeding, and a high index of suspicion in such
circumstances is important.
●The experienced surgeon will perform on-table endoscopy prior to embarking on
surgery .
●The stomach is opened by longitudinal gastrotomy and the upper section is
carefully inspected. It is normally possible to palpate the longitudinal mucosal tear
with a little induration at the edges, which gives a clue to the lesion’s location.
Underrunning is all that is required.

40. Portal hypertensive gastropathy

41. Portal hypertensive gastropathy
●Refers to change in the mucosa of the stomach in patient with portal
hypertension , most common cause is liver cirrhosis and portal vein thrombosis
which lead to gastric varices and esophageal varices that tend to rupture and
perforate causing bleeding
●By endoscopic intervention can determine the varices
●The first line of treatment is by band ligation therapy and if it is failed , then doing
transjugular intrhepatic portosystemic shunt (TIPS)

42. Tumours
●Can be beningn or malignant
●Beningn tumours of the stomach and duodenum are not
common and constitute only 5-10hcamots lla fo %
, ralucsav , lamyhcnesem ,lailehtipe rehtie si ti, sruomut
cinegoruen
●The most commn presenting symptom is bleeding
●Treatment is endoscopic resection or by open surgery

43. ●Most common malignant tumours
1-Adenocarcinoma 95%
2-Lymphoma 4%
3-Malignant gastrointestinal stromal tumour 1%
●Treatment is by excision of tumor (total or subtotal gasterectomy ) with chemo or
radiotherapy if there is lymph node involvement or metastasis

44. Vascular malformation: Dieulafoy’s disease
•This is essentially a gastric arterial venous malformation that has a
characteristic histological appearance .
•Bleeding due to this malformation is one of the most difficult causes of upper
gastrointestinal bleeding to treat ..

45. ●The lesion itself is covered by normal mucosa and, when not bleeding, it may be
invisible. If it can be seen while bleeding, all that may be visible is profuse
bleeding coming from an area of apparently normal mucosa. If this occurs, the
cause is instantly recognisable.
●If the lesion can be identified endoscopically there are various means of dealing
with it, including injection of sclerosant and endoscopic clips .
●If it is identified at operation then only a local excision is necessary .
●Occasionally, a lesion is only recognised after gastrectomy and sometimes not
even then. The pathologist, as well as the endoscopist, may have difficulty in
finding it.

46. Aortic enteric fistula
•This diagnosis should be considered in any patient
with haematemesis and melaena that cannot be
otherwise explained.

47. Aortic enteric fistula
Contrary to expectation, the bleeding from such patients is not always massive,
although it can be.
Very often there is nothing much to distinguish between the bleeding from the
aortic enteric fistula and any other recurrent upper gastrointestinal bleeding.The
vast majority of patients will have had an aortic graft and, in the absence of this,
the diagnosis is unlikely .
However, it is occasionally seen in patients with an untreated aortic aneurysm. A
well-performed CT scan will commonly allow the diagnosis to be made with
certainty. The condition should be managed by an expert vascular surgeon as,
whether secondary or primary, the morbidity and mortality are high.

48. References:
1. Bailey & Love’s SHORT PRACTICE of SURGERY 26th EDITION
2. BROWSE’S INTRODUCTION TO THE SYMPTOMS & SIGNS OF SURGICAL
DISEASE 5th ed
3. Schwartz’s Principles of Surgery Tenth Edition
4. American college of gastroenterology .Management of peptic ulceration.
retrived from https://gi.org/guideline/management-of-patients-with-ulcer-
bleeding/
5. Textbook of Surgery 3
rd
ed
6. Macleod’s Clinical Diagnosis 1
st
ed