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GERICLINICS

GeriQBank · Paper III · Q6

Haematemesis

High YieldAsked ×27-mark note
Topic
Gastroenterology & Hepatology
Chapter
Gastroenterology & Nutrition
Years asked
Not recorded in the source
Frequency
Set 2× in Paper III (2009–2025)

As set in the university paper

  • Approach to upper gastrointestinal bleed / haematemesis.

    Paper III · Gastroenterology & Nutrition · asked ×2 · 7-mark note · see in paper list

    Linked automatically by wording similarity — check that this answer matches the question as set.

Answer framework

  1. Definition and mimics — vomited blood or coffee grounds; haemoptysis and swallowed blood
  2. Causes in older people
  3. Severity assessment and resuscitation
  4. Risk stratification, transfusion and antithrombotics
  5. Endoscopy and treatment; variceal bleeding
  6. Prevention
  7. Recent updates

An exam answer plan drawn from the detailed answer below. Use it to attempt the question first.

Detailed answer

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Attempt it firstOutline your answer as a 7-mark note before revealing it — definition, causes, evaluation, management and the geriatric angle.Reveal answer

Short revision answer

  • Haematemesis is vomiting of blood or coffee-ground material from above the ligament of Treitz — an alarm symptom needing prompt endoscopy at any age. Distinguish haemoptysis (frothy, with cough) and swallowed blood from the nose or throat.
  • Causes in older people: peptic ulcer (NSAIDs, aspirin, steroids, H. pylori), erosive gastritis, varices, oesophagitis including pill oesophagitis, Mallory–Weiss tear, Dieulafoy lesion, angiodysplasia and gastric or oesophageal cancer.
  • Assess pulse, BP, postural drop, capillary refill, urine output and mental state. Tachycardia may be blunted (age, beta blockers), so shock is under-recognised.
  • Resuscitate first: two wide-bore cannulae, crystalloid, oxygen, cross-match and airway protection. Send CBC, urea (raised urea with normal creatinine suggests an upper source), creatinine, LFTs and coagulation.
  • A Glasgow–Blatchford score of 0–1 allows outpatient care. Transfuse below Hb 7 g/dL (target 7–9 g/dL; 8 g/dL with cardiovascular disease). Use PCC, not FFP, to reverse warfarin with instability, and continue secondary-prevention aspirin.
  • Endoscopy within 24 hours, after erythromycin 250 mg IV. Treat Forrest Ia, Ib and IIa lesions, then high-dose PPI for 3 days and twice-daily oral PPI for 2 weeks. Varices: terlipressin or octreotide, ceftriaxone, band ligation and early TIPS; embolisation if endoscopy fails.
  • Prevent recurrence: eradicate H. pylori, stop NSAIDs, give PPI cover with antithrombotics, and biopsy or re-scope gastric ulcers.
  • Updates: restrictive transfusion is confirmed safe (2023); tranexamic acid is not recommended; FFP in variceal bleeding raises 42-day mortality; vonoprazan is emerging for preventing rebleeding after haemostasis.

Condensed by GeriClinics from the detailed answer below, with no new facts added.

6.

Haematemesis

7 MARKS

1.

Haematemesis is vomiting of frank blood or coffee-ground material, indicating bleeding proximal to the ligament of Treitz. It is an alarm symptom mandating prompt endoscopy at any age, and Pathy's specifically lists it among the alarm symptoms requiring urgent investigation.

2.

Distinguish from mimics: haemoptysis (frothy, bright red, alkaline, with cough) and swallowed blood from epistaxis or oropharyngeal bleeding. Coffee-ground appearance reflects acid conversion of haemoglobin to haematin.

3.

Common causes in the elderly: peptic ulcer (NSAIDs, aspirin, steroids, H. pylori), erosive gastritis, oesophageal and gastric varices, oesophagitis including pill oesophagitis, Mallory–Weiss tear, Dieulafoy lesion, angiodysplasia, and gastric or oesophageal malignancy.

4.

Assess severity immediately: pulse, blood pressure, postural drop, capillary refill, urine output and mental state. Remember the blunted tachycardic response in older patients and those on beta-blockers — shock is under-recognised.

5.

Resuscitate first, investigate second: two wide-bore cannulae, crystalloid, oxygen, cross-match, and airway protection with massive haematemesis or encephalopathy. Send CBC, urea and creatinine (raised urea supports an upper source), LFTs and coagulation.

6.

Risk stratify with the Glasgow–Blatchford Score — a score of 0–1 identifies very-low-risk patients suitable for outpatient management; all others are admitted.

7.

Transfuse restrictively at a haemoglobin threshold of 7 g/dL (target 7–9 g/dL), or 8 g/dL if there is cardiovascular disease. Withhold anticoagulants, use PCC rather than FFP for warfarin reversal with instability, and continue aspirin prescribed for secondary prevention.

8.

Endoscopy within 24 hours (earlier if unstable), preceded by erythromycin 250 mg IV to clear the stomach. Apply combination endoscopic haemostasis for Forrest Ia, Ib and IIa lesions, then high-dose PPI for 3 days followed by twice-daily oral PPI for 2 weeks.

9.

If variceal: terlipressin or octreotide, prophylactic ceftriaxone, and band ligation; consider early TIPS. If endoscopy fails, proceed to transcatheter embolisation before surgery.

10.

Prevention: eradicate H. pylori, stop NSAIDs, co-prescribe PPI where antithrombotics must continue, and always biopsy or re-scope a gastric ulcer to exclude malignancy.

Latest Updates (2023–Present) — concise

Restrictive transfusion at 7 g/dL is confirmed safe by 2023 meta-analysis, with no excess mortality or rebleeding and fewer transfusion reactions; thresholds above 8 g/dL may worsen outcomes (Sci Rep, 2023). Tranexamic acid is not recommended in acute GI bleeding, and FFP in variceal haemorrhage is associated with increased 42-day mortality (ESGE, 2021–2022; ACG, 2023).

Vonoprazan is emerging as an alternative to intravenous PPI for preventing rebleeding from high-risk ulcers after endoscopic haemostasis (cited in AGA P-CAB Clinical Practice Update, 2024).

Current Practice Update

Textbook position Current evidence

Haematemesis treated as an alarm symptom requiring Unchanged — but now with a defined 24-hour window and formal prompt endoscopy. risk scoring for safe outpatient management.

No transfusion or reversal protocol specified. Hb 7 g/dL threshold (8 g/dL with cardiovascular disease); PCC over FFP; no routine platelets, vitamin K or tranexamic acid.

Examiner's Tip

"Resuscitation precedes endoscopy — but endoscopy within 24 hours changes outcome." "A raised urea with normal creatinine supports an upper gastrointestinal source." "Never discharge an older patient with haematemesis on symptom resolution alone — score them."

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