Haematemesis is very distressing for patients and carers and needs urgent assessment. It ranges from a single blood-streaked vomit to a catastrophic, life-threatening bleed.
A modifiable cause with a reasonable prognosis may warrant admission and endoscopy; the same bleed in the last days of life is managed with comfort, not investigation.
Recognising who is at risk is crucial. You can reduce contributing factors and update the Universal Care Plan (UCP).
Quick summary
Triage treatable vs terminal against prognosis and goals of care.
Treatable
Stop NSAIDs / steroids/ anticoagulants / antiplatelets / SSRIs. Tranexamic acid 1g tds + PPI. Endoscopy if appropriate.
Terminal
Stay with the patient. Dark towels. Midazolam 10mg IM / IV / buccal if available, repeat at 10 min. Add morphine for pain,distress or breathlessness.
Common causes
Treatable:
- Gastritis/duodenitis (often NSAIDs, corticosteroids or recent chemotherapy)
- Low platelets
- Drug-induced (anticoagulants, antiplatelets)
Probably irreversible:
- Tumour bleeding (gastric, duodenal or oesophageal)
- Oesophageal varices from portal hypertension (hepatic malignancy or cirrhosis)
- Coagulopathy
Recognising who is at risk
- known varices, or an upper GI or hepatic tumour
- a herald (smaller warning) bleed, or falling Hb
- on anticoagulants, antiplatelets, NSAIDs or corticosteroids
Planning for those at risk
- stop high risk drugs (anticoagulants, antiplatelets, NSAIDs, corticosteroids)
- ensure resuscitation status is documented including treatment escalation
- crisis medication is prescribed on the MAAR chart and available; carers know where it is, who can give it, and who to call
- dark towels/sheets, gloves, aprons and waste bags are to hand
- carers have an emergency number
- update the Universal Care Plan (UCP) so that all teams, including out-of-hours and paramedics, are aware
- consider how much information would be valuable for the patient and family to know about this risk
Managing a treatable bleed
- Decide whether blood tests and endoscopy are appropriate (endoscopy can be diagnostic and therapeutic; consider admission)
- PPI (can be oral or subcut) or an H2 blocker such as famotidine
- Medication review: consider switching an SSRI to mirtazapine or an NSAID to celecoxib or etoricoxib
- Discuss with haematology if abnormal clotting or low platelets - treatment with vitamin K or platelets may be considered
- Tranexamic acid 1g three times a day - either oral or subcut
- Sucralfate 2g in 10ml for oesophageal lesions (do not use with a PPI but can be very effective)
- Consider transfusion
- Radiotherapy may be appropriate/consult oncologist
Managing a catastrophic (terminal) bleed
Consciousness is lost quickly. Calm presence and reassurance matter more than any drug - stay with the patient rather than leave to fetch medication.
- Call for help; keep talking to and reassuring everyone present
- Dark towels to reduce the visual impact of blood; recovery position if appropriate
- Ask a carer to sit behind the patient, this limits blood contact, lets them keep reassuring
- Suction (if available) only if choking or aspirating
- If distressed and crisis medication is to hand: midazolam 10mg IM. Repeat after 10 minutes if not unconscious; add morphine (e.g. 5-10 mgs) for severe distress
- If bleeding/vomiting continues and death is expected soon: and infusion with midazolam infusion + levomepromazine (or haloperidol) +/- an opioid would be appropriate