A 76-year-old male presents with a small amount of coffee-ground vomitus earlier in the day. He has no ongoing vomiting, his vital signs are normal and he has a negative guaiac test for faecal occult blood.
Which ONE of the following is the MOST appropriate answer?
Answer: C: Bleeding from an upper GIT source stops spontaneously in most cases and requires no further intervention. It would therefore be useful if we could reliably identify patients at low risk for rebleeding and death, as these patients are unlikely to require endoscopic intervention and could potentially be managed as outpatients. Current recommendations advise admission for all patients and endoscopy within 24 hours as the sensitivity of endoscopy is optimised if performed within 12–24 hours of presentation. Early endoscopy allows the prediction of likelihood of rebleeding and mortality, according to the nature and location of lesion and stigmata of recent haemorrhage.
Risk stratification using a combination of clinical and endoscopic findings has been well validated as a means of predicting the risk of rebleeding and in-hospital mortality. The Rockall score is an example of such a scoring tool and frequently used for risk stratification. However, only a small number of studies looked at risk stratifying patients solely on clinical features without including endoscopy findings. These studies suggest that a subset of low-risk patients may be discharged safely with an upper GIT bleed. Characteristics of these low-risk patients included:
The Glasgow-Blatchford bleeding score is a scoring tool based solely on clinical and laboratory criteria. It has been suggested that selected patients can be safely discharged and managed as outpatients without early endoscopy as they are unlikely to need treatment and therefore may not require admission if they satisfy the following criteria:
Interestingly, it does not include age despite the fact that age >65 years has been associated with an increased risk of rebleeding and death. Although promising, clinical predictive scores are not yet widely accepted and still need further validation to make a graded recommendation.
Peptic ulcer disease may be painless, especially in the elderly and particularly in those taking NSAIDs or steroids. Rectal examination and faecal occult blood testing should be performed in all patients with suspected upper GIT bleeding. A positive test requires at least 8 mg of haemoglobin per gram of stool. A positive guaiac test is dependant on the time of onset of the bleeding in relation to gastrointestinal transit time. It is therefore possible that in some acute bleeds, the blood may not have traversed the bowel by the time testing is done. Falsepositive guaiac tests can be caused by certain bacterial and vegetable peroxidases, such as bananas and horseradish. Therapeutic iron intake is commonly believed to cause false-positive guaiac testing. Most studies in vivo, however, have shown that this is not a common cause of false-positive testing.
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Regarding the management of a 40-year-old male presenting with massive haematemesis, which ONE of the following is TRUE?
Answer: C: Traditionally, gastric lavage was thought to decrease bleeding or rebleeding, particularly if cold water was used, but the evidence does not support this. Cold water may indeed exacerbate bleeding. Gastric lavage is now mainly used to allow better visualisation during endoscopy and room-temperature water is recommended.
PPIs are recommended before endoscopy, as they reduce the likelihood of bleeding or need for intervention during endoscopy. It also significantly reduces the risk of rebleeding and blood transfusions. A recent metanalysis showed no change in mortality though.
Octreotide reduces splancnic blood flow and portal venous pressure while preserving cardiac output and SBP. It is therefore useful for upper GIT bleeds of variceal origin. However, octreotide has also been shown to decrease the risk for persistent bleeding and rebleeding in patients with PUD, although the results are conflicting, and may be considered in patients awaiting endoscopy. Concerns that NGT placement may provoke bleeding in patients with varices are unwarranted and NGT can safely be used in these patients.
Regarding a 45-year-old male with liver cirrhosis and known oesophageal varices presenting with haematemesis, which ONE of the following is TRUE?
Answer: B Variceal bleeding may be catastrophic, with 30% mortality for a first bleed. Early control of bleeding should be achieved. Significant advances in the treatment of acute variceal bleeding have been made since the era of balloon tamponade with the Sengstaken-Blakemore tube. This is now rarely used due to significant complications and rebleeding upon balloon deflation but should still be considered as a temporising measure if bleeding is uncontrolled and pharmacological options and endoscopy are not immediately available. After insertion of the tube, the gastric balloon is inflated first with air and the tube pulled until resistance is felt, at which point the balloon is tamponading the gastro-oesophageal junction. If bleeding continues despite inflation of the gastric balloon, the oesophageal balloon should be inflated, taking care not to overinflate the oesophageal balloon as it may cause oesophageal necrosis or rupture.
Advances include endoscopic techniques, mainly sclerotherapy or band ligation, and vasoactive pharmacological options like octreotide. Sclerotherapy was the first available endoscopic therapy for bleeding varices. It is effective in controlling bleeding and reduces rebleeding and the need for blood transfusion. It is, however, associated with significant complications including deep oesophageal ulcerations, strictures, mediastinitis, pleural effusions, sepsis and death. Endoscopic band ligation appears to be more effective and associated with fewer complications and is the preferred endoscopic treatment in most cases.
Pharmacological therapy with octreotide is comparable to injection sclerotherapy in terms of bleeding control and with the advantage of fewer side effects. Additionally, combination endoscopic and pharmacological therapy improves initial haemostasis and early rebleeding rates. It is therefore imperative that octreotide infusion be initiated as soon as possible to all patients with suspected varices.
Up to 81% of patients with known varices have an alternative bleeding site. Intravenous PPI, such as esomeprazole, should therefore be initiated early for presumed PUD, oesophagitis, gastritis or duodenitis. Infection occurs in 35–66% of patients with cirrhosis and gastrointestinal bleeding. Not only does it carry the risk of sepsis but concurrent infection also impairs coagulation, thereby increasing the risk or rebleeding. Several studies have shown that antibiotic prophylaxis in cirrhotic patients with gastrointestinal bleeding improves mortality and reduces the risk of further bleeding. Gram-negative bacteria have been most commonly isolated in these patients. Fluoroquinolones have been traditionally used in the past but recent resistance patterns have encouraged the use of third-generation cephalosporins.
Regarding the clinical examination of patients with suspected liver disease, which ONE of the following is TRUE?
Answer: D: A normal liver span usually measures 8–13 cm in the midclavicular line. Percussion is the only clinical method to measure the span of the liver. Measurement of the liver span is more important than the presence of a palpable liver edge to detect hepatomegaly, as 80% of people have some palpable extension of the liver beyond the costal margin. Palpation of the liver edge may be normal, due to enlargement or due to lung hyperinflation. Extension of the liver >2 cm beyond the rib margin is, however, most likely due to hepatomegaly.
The presence of ascites is suspected in patients with abdominal distension, bulging flanks, flank dullness to percussion, shifting dullness to percussion, and/or a fluid thrill. Bulging flanks are 80% sensitive in the detection of ascites but only 50% specific, whereas a fluid thrill is only 60% sensitive but 90% specific. Spider naevi is usually found in the superior vena cava (SVC) distribution. They may occur on normal individuals but the presence of >5 are abnormal and chronic liver disease should be suspected.
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Regarding the detection of ascites and interpretation of ascitic fluid results, which ONE of the following is TRUE?
Answer: A: The accuracy of physical findings to detect ascites is variable and depends in part upon the amount of fluid present, the technique used to examine the patient, and the clinical setting. Approximately 1500 mL of fluid has to be present for flank dullness to be detected; therefore, lesser degrees of ascites can be missed. If no flank dullness is present, the patient has a 10% chance of having ascites. Ultrasonography can be helpful when the physical examination is not definitive.
Ascitic fluid had been classified as an exudate if the total protein concentration is ≥ 30 g/L and a transudate, if it is <30 g/L. However, the exudate/ transudate system of ascitic fluid classification has been replaced by the SAAG, which is a more useful measure for determining whether portal hypertension is present. SAAG has been proved in many prospective studies to categorize ascites better than the total protein-based exudate/transudate concept. Calculating the SAAG involves measuring the albumin concentration of serum and ascitic fluid specimens obtained on the same day and subtracting the ascitic fluid value from the serum value:
A cell count and differential should be performed in all patients undergoing abdominal paracentesis. Cirrhotic ascites should generally contain <250 WBCs/µL. Up to 500 WBC/mm3 is acceptable in uncomplicated cirrhosis. Lymphocytes should predominate, and clinical signs or symptoms of peritoneal infection should be absent.
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