Mansoura University

Faculty of Medicine

LEVEL 3
SEMESTER 6
Hepatology and gastroenterology
TREATMENT PLAN
OF HEMATEMESIS
AND MELENA IN
SPECIAL
SITUATIONS
 Instructor information

• Contact:
Hepatology and gastroenterology unit- internal medicine
department
• Official email: omarelmetwally10@mans.edu.eg
 Lecture outline
* Most common causes and risk factors for hematemesis and
melena

* Management plan of hematemesis and melena in special

situations ( cardiac, renal patients and during pregnancy)

*Which endoscopic techniques are used in the treatment of

upper gastrointestinal bleeding (UGIB)?
 Risk factors causes

- Peptic ulcer
- Portal hypertension
(varices, portal
- Cardiac patient hypertension)
- NSAIDs - Esophagitis
- Renal patient - Gastritis
- Pregnancy - Vascular lesions (GAVE,
- Malignancy Angiodysplasia,
Dieulafoy)
- Mallory-Weiss
syndrome
 Cardiac patient or any patient on anticoagulation and/ or
antiplatelets

 For most patients, endoscopy should not be delayed

because of anticoagulant or antiplatelet agent use

 Provided the patient is hemodynamically stable, urgent

endoscopy can usually proceed simultaneously with
management of antithrombotic medications

 However, for patients undergoing upper endoscopy, we

wait until the INR is <2.5 to perform the endoscopy, if
possible.
 When possible, anticoagulants and antiplatelet agents should be held in
patients with acute upper GI bleeding.

 In patients with severe, ongoing bleeding who are taking an

anticoagulant, administration of a reversal agent or intravenous
prothrombin complex concentrate may be indicated.

 However, the thrombotic risk of reversing anticoagulation should be

weighed against the risk of continued bleeding without reversal, and
thus the decision to discontinue medications or administer reversal
agents needs to be individualized.
 NSAIDs
 Discontinue NSAIDs when feasible in
patients with bleeding from gastric or
duodenal ulcers
 Selective cyclooxygenase (COX)-2
inhibitors could be substituted, with a
reduction in the risk of recurrent ulcer
bleeding
 Continued concomitant use of PPIs also
reduces the risk of recurrent ulcer
bleeding.
 Renal patients

Causes: Mechanisms:
- Gastroduodenal - uremia-induced
ulcers, platelet
- esophagitis, dysfunction and
- vascular ectasia and - increased risk of
- gastric and duodenal vascular
erosions malformation
 Management

symptomatic treatment with proton pump inhibitors, antacids and antiemetic

drugs, and hemodialysis.

Urgent upper GIT endoscopy is not always necessary to be conducted in every

CKD and ESRD on hemodialysis unless patients have severe symptoms or
highly suggestive aggressive lesion that cause massive hematemesis and/or
melena or severe anemia and/or shock
 Pregnancy

Management:
- Good history taking (may identify the
Causes: cause)
- Mallory- Weiss tear - Full blood count, electrolytes, renal
- Esophagitis with or and liver functions
without hiatus hernia - IV fluids and blood if needed
- Gastric/ duodenal - Nil by mouth if moderate to severe
ulcer or erosions bleeding
- Appropriate antacids medications
- Gastroenterology consultation
 When emergency or urgent indications are present,
endoscopic procedures may be considered with some
precautions
 All gastrointestinal endoscopic procedures in pregnant
patients should be performed in hospitals by expert
endoscopists and an obstetrician should be informed about
all endoscopic procedures.

 The endoscopy and flexible sigmoidoscopy may be safe for

the fetus and pregnant patient, and may be performed
during pregnancy when strong indications are present.
 Which endoscopic techniques are used in the treatment of upper
gastrointestinal bleeding (UGIB)?
 Injection of epinephrine or sclerosants

 Band ligation

 Argon plasma coagulator (APC)

 Application of hemostatic materials, including biologic glue and tissue

adhesives
 Application of hemostatic powder/spray

 Application of hemoclips/endoclips or over-the-scope clips

 learning outcomes

By the end of the lecture, the students will be able to know:

- causes and risk factors for hematemesis and melena
- How to manage hematemesis and melena in special situations
- Which endoscopic techniques are used in the treatment of upper
gastrointestinal bleeding (UGIB)
Case scenario, clinical correlate, practice points

67 years old male with history of hypertension and osteoarthritis who

present to emergency department with 3 episodes of coffee- ground
emesis today
no abdominal pain, melena or bleeding per rectum. No history of liver
disease or coagulopathy

Medications include, Lisinopril, hydrochlorothiazide and ibuprofen

for joint pain
vital signs on arrival:
Temp 37, H.R 102, BP 108/72, oxygen sat 99% on room air

Examination:
No jaundice, abdomen soft not tender, no hepatosplenomegally

Labs:
HB 9.8, PLT 245, INR 1, liver and kidney function tests were
normal
what are the major causes of hematemesis?

Different characteristics of bleeding:

* Hematemsis….
* Melena….
* Hematochezia….

Role of history in initial evaluation for a case of hematemesis:

- Diseases
- Drugs
- Surgery
Clinical evaluation:
- Vital signs
- Abdominal examination
- Skin examination
- DRE
- Nasogastric tube (ryle)

Diagnostic evaluation:
- CBC, INR
- Liver and kidney function tests
- Others..
Emergent management:
- Closely monitor airway, clinical status, vital signs
- Two large bore IV lines
- Bolus infusion of isotonic crystalloid
- Transfusion of packed RBCs, PLT or fresh frozen plasma if needed
- Immediate gastroenterologist consultation
 LEARNING OUTCOME 1

• Obtain a good history to identify potential sources of upper GI

bleeding and assessing its severity
 LEARNING OUTCOME 2

• Examination and diagnostic data should focus on signs that indicate

the severity of blood loss, help localize the source of bleeding, and
suggest complications
 LEARNING OUTCOME 3

• How to do emergent management of a case of upper GI bleeding

 Summary and wrap up
- Upper GI bleeding is considered one of the major gastroenterology
problems
- Pregnancy, cardiac and renal patients were considered a risk factors for
hematemesis
- Good history taking and good clinical examination are important keys
for identifying the cause of hematemesis
- Initial management of hematemesis with vital and hemodynamic
stability is the first and most important step in the treatment plan
THANKS