Case 11: Managing Haematemesis

Mrs Tollings is a 43 year old woman presenting to the emergency department having vomited blood

drip stand

Mrs Tollings is a legal secretary who is normally in good health and on no prescribed medications. She lives alone, is a non-smoker and drinks approximately 5 bottles of white wine per week.

On admission Mrs Tollings has active haematemesis and is reviewed by the Emergency Department Registrar. ABCDE assessment is as follows:

A – clear, talking

B – RR 28, Sats 99% on air, clear chest

C – HR 124 (regular), BP 110/68. Cool, clammy hands and feet.

D – Alert. Capillary blood glucose 7.8.

E – Soft, mildly tender abdomen. Black tarry stool (melaena) noted on rectal examination.

Initial blood tests:
Hb 9.2 g/dL
WCC 12.0 x109/L
Plt 120 x109/L
Na 146 mmol/L
K haemolysed (3.4 mmol/L on a venous blood gas sample)
Urea 19 mmol/L
Creatininer 120mmol/L
LFTs haemolysed
Clotting sample bottle under filled.

Question 1:

  1. Is there anymore information you would like to know from Mrs Tolling’s history and examination that would help to narrow your diagnosis and formulate a management plan?

Further information released during the week:

Further history:

–       No vomiting prior to the haematemesis

–       Has some longer term symptoms of epigastric burning and thinks she may have had black stools a few times

GI Bleeding Risk factors

–       Takes Ibuprofen almost every day for tension headaches

–       Has drunk this amount of alcohol for one year but has no stigmata of chronic liver disease on examination

–       Has not had peptic ulcer disease in the past/never knowingly been infected with H.Pylori.

–       She has no known bleeding disorders and reports no blood loss from other sites

After initial medical management to ensure she was stable Mrs Tolling’s had an OGD (picture shown below).

Endoscopy finding

Discuss now on Twitter, using the hashtag #quclms. Follow @quclms for updates. Further information and follow-up questions will appear on Twitter throughout the week.

Question setter: Dr Beth Good, ST4 Acute Medicine & Clinical Teaching Fellow UCLMS

Expert: Dr David Graham , ST7 Gastroenterology & PhD Research Fellow at UCL (Interventional Science Department)

For tips on following hashtags read more, and try one of our recommended Twitter plugins.

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