1. Gastrointestinal Haemorrhage
Mrs Esther Mitchell
Clinical Teaching Fellow

2. Acute Block Objectives
GI Bleeds
Assess the likely causes of upper GI bleeds from history and examination
Initiate management of acute upper GI bleeds
Distinguish common causes of lower GI bleeds from history and examination
Initiate appropriate investigations for lower GI bleeds
Assessment of the Acutely ill patient
Resuscitation

3. Today’s Objectives Knowledge
Know what colours are likely to represent blood in a vomit or stool sample
Understand why blood changes colour in the GI tract
List common causes of lower GI bleeds
Know symptom complexes that clinically differentiate these causes
Know the initial management of upper GI bleed patients
List features on history and examination that suggest Varaceel bleeds
List 5 other causes of upper GI bleed
Describe the distinguishing features of these other presentations

4. Today’s Objectives continued
Knowledge continued
Understand resuscitation of bleeding patient, including use of fluids and blood
Think about different types of investigations and what information can be obtained from them
Skills
Fill in an upper GI bleed care pathway
Be able to calculate a Rockal score
Prescribe blood and IV drugs correctly
Attitudes
Appreciate knowing purpose of investigations allows correct choice of investigation
Be aware of how serious upper GI bleeds can be
Give GI bleed patients appropriate priority

5. Outline Patient Pathways General principles & Worked Examples
Recognising a GI Bleed
Causes of GI Bleeds
Management
Investigations
Including Case Study Group work sessions

6. Patient Pathway – “Normal”
Treatment
Presentation
History & Examination
Provisional Diagnosis
Investigations
Specific Diagnosis

7. Patient Pathway – “Acute”
Presentation
Unstable Patient
Specific Treatment
Stable Patient
Further Investigations
Confirm Diagnosis
Resuscitation
Haemostasis
Medical Management
Investigations
History & Examination
Working Diagnosis

8. Recognise a GI Bleed

9. What’s blood? What colours can blood be?
Why does it change colour in the GI tract?
Do you always see blood if there’s GI bleeding?
Chat to neibours for 30s – 1 min
Answers called out

10. Colours of Blood Colour Vomit Stool Bright Red √ Dark Red x Green
Black
Brown
x ?
No motion / vomit ?

11. Why does blood change colour?
Stomach – Acid
Bright Red -> brown / coffee grounds
Small Bowel – Digestive enzymes
Bright Red -> Dark Red
Colon – Bacteria
Bright Red-> Dark Red -> Black

12. PR Bleeds (haematochezia)
Black – Cecum or Upper GI
Melaena, Tar like, smelly
Dark Red – Transverse colon, Cecum
Or Upper GI, large volume
Loose / soft stools
mixed with stools
Bright Red – Anus, Rectum, Sigmoid
Mixed with stools - sigmoid / descending
Coating stools / on paper – rectal / anal
Rarely massive upper GI bleed

13. Consider occult GI blood loss when:
Unexplained anaemia
Low volume chronic bleeds, eg Gastric Ca, Cecal Ca
Sudden episode of hypotension and tachycardia, easily corrected
Acute upper GI bleed
melaena follows hours later
History of bleeds / risk factors, shocked pt
Symptoms missed, or appear later

14. Causes of GI Bleed Brainstorm all causes of GI bleeds
Groups, 2-4 people
2 minutes
Make 2 lists, most common to least common
Divide into upper & lower GI causes
1minute
Ask groups to call out most common upper GI bleed, then show list. Likewise with Lower GI causes. Don’t let it drag

15. Causes - Upper GI (80%) Peptic ulcer disease – 50%
Erosive Gastritis / Oesophagitis – 18%
Varices – 10%
Mallory Weiss tear – 10%
Cancer – Oesophageal or Gastric – 6%
Other, including Dieulafoy’s lesion – 6%
Mallory Weiss is a laceration at the junction of the oesophagus and stomach, due to forceful coughing or vomiting.

16. Causes - Lower GI (20%) Diverticular disease - 60%
Colitis (IBD & ischaemic) – 13%
Benign anorectal (haemorrhoids, fissures, fistulas) – 11%
Malignancy – 9%
Coagulopathy – 4%
Angiodysplasia – 3%
Post surgical / polypectomy
Angiodysplasia – vascular malformation, often small but multiple, causing subtle symptoms. Ischaemic colitis – usually elderly people, cause for ischaemia generally unknown but can be embolic.

17. Management Urgency of Management Resuscitation including Transfusion
Medical Management
Haemostasis
Treatment of underlying disease

18. Urgency of Management Severe bleeds Moderate bleeds
Resuscitation
IP investigation +/- treatment
Moderate bleeds
IP observation till bleed stops
Often OP investigation +/- treatment
Mild / low risk bleeds
Early discharge
OP investigation +/- treatment

19. Severe Bleeds Severe / significant bleed if any of the following:
Tachycardia >100
Systolic BP <100 (prior to fluid resuscitation)
Postural hypotension
Symptoms of dizziness
Decreasing urine output
Evidence of recurrent melaena / haematemesis / PR bleeding (haematochezia)

20. Low risk patients
Consider for discharge or non-admission with outpatient follow-up if:
Age <60, and;
No evidence of haemodynamic disturbance (SBP > 100mmHg, pulse < 100bpm), and;
Not a current inpatient or transfer, and;
No witnessed haematemesis or haematochezia (upper GI bleed) or
No evidence of gross rectal bleeding, and an obvious anorectal source of bleeding on rectal examination +/- rigid sigmoidoscopy (lower GI bleed)

21. Introduction to Upper GI Bleed Pathway
3 minutes, working individually
Fill in pathway for Case 1
Need:
coloured case study sheet (any colour)
Upper GI bleed pathway
Use your imagination to fill in details not stated!!!

22. Case 1
PC/HPC 18F
Vomited x4 tonight, now streaks of red blood on 3rd and 4th vomits
Has been out with friends tonight, had “a few drinks”
PMH – Fit and well
Drugs & Allergies – Nil
O/E Pulse 80 reg, BP 110/80 (no postural drop)
Abdomen soft, non-tender, no organomegaly
PR - empty rectum
Rest of examination normal

23. Case 1 Diagnosis Severity Rockall Score Ix and Mx Mallory Weiss tear
Mild
Rockall Score
Age 0, Shock 0, co-morbidity 0 = 0
Ix and Mx
Senior r/v with view to discharge and OP OGD

24. Rockall Score (Upper GI only)
Variable 1 2 3
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
Co-morbidity
No major cormorbidity
CCF, IHD, major comorbidity
Renal failure, liver failure, malignancy
Diagnosis
(Post OGD)
Mallory-Weiss tear, no lesion identified, no SRH
All other diagnoses
Malignancy of upper GI tract
Major stigmata of recent haemorrhage
None or dark spot only
Blood in GI tract, adherent clot, visible or spurting vessel
Pre OGD Score
0-1 next available list (Mortality <2.5%)
>=2 urgent OGD (Mortality 5%)
Post OGD Score
<3 good prognosis, early discharge
>8 high risk of death 24

25. Endoscopy – Upper GI Bleeds
Severe bleeds
Urgent OGD, inform Surgeons and Critical Care
Suspected Varceal bleed
Continued bleeding, >4u blood to keep BP >100
Continuing fresh melaena / haematemesis
Re-bleed / unstable post resuscitation
If fails, may need emergency surgery
Moderate bleeds
IP OGD within 24hrs
Minor bleeds / unproven
Consider OP OGD

26. Mallory Weiss tear

27. Mallory Weiss tear Hx Ex Vomiting (++) prior to haematemesis
Often associated with alcohol
Small volume blood “streaks”, mixed with vomit Ex
Normal examination

28. Benign Anorectal Haemorrhoids Anal Fissure Fistula in aino
Bright red blood on toilet paper, not mixed with stools
Diagnosed by typical PR appearances
Haemorrhoids
Feel “lump”, Itch
Anal Fissure
Anal pain +++ with motions
Fistula in aino
Soiling on underwear, recurrent abscesses

29. Anal Fissure

30. Haemorrhoids

31. Fistula in aino

32. Moderate & Sever Bleeds

33. Resuscitation
Airway
Breathing
Circulation
Disability
Exposure

34. Airway & Breathing Large clots can block the airway
May have reduced conscious level (shock/encephalopathy)
At risk of aspiration due to vomiting
Give 15l/min oxygen via face mask 34

35. Circulation – recognising shocked patients
Pale
Clammy skin
High Cap Refill (>2s)
Weak pulse
Tachycardia (NB beta blockers)
Hypotention
(High resp rate)
(Confusion)

36. Circulation - Interventions
2 large bore IV cannulae (14 or 16 G)
Send blood for FBC, clotting, G&S or X-match, if bleeding is severe inform blood bank (see also massive haemorrage protocol)
IV fluids to maintain BP>100 systolic
Start with up to 2l N Saline Stat
Then progress to blood
IV FFP if variceal bleed suspected or INR>1.3
Urinary catheter
Cross match at least six units for bleeding varices. 36

37. Blood

38. Blood O Negative Type specific (red label ...) Fully X matched
immediately
shock not responding to IV fluids
Type specific (red label ...)
20 mins
transient response, ongoing bleed
Fully X matched
40 mins plus
responded to fluids, but significant blood loss
Speak to lab technician they will know exact times!
Consider massive haemorrhage alert protocol

39. Massive Haemorrhage Protocol
Purpose:
to improve and streamline blood administration to those with massive blood loss
Massive Hemorrhage protocol kicks in in the following circumstances:
Blood loss
of 1 blood volume (5l) within 24hrs or
of 50% blood volume (2.5l) within 3hrs
at rate of 150 mls/min

40. Medical Management Stop Give Consider Antihypertensives NSAIDS
Anticoagulants
Give
10mg IV vitamin K if INR >1.3
Consider
2mg IV Terlipressin (stat then QDS)
Broad spectrum antibiotics (e.g. Tazocin 4.5g tds)
40mg IV Omeprazole bd
40mg oral Omeprazole od

41. Prescribing exercise
Jo Blogs (dob 01/01/1955, hospital no X111000) is in Resus unstable with a massive upper GI bleed (probably variceal)
Please prescribe him:
2 units of blood
IV Tazocin
IV Terlipressin
Hand in your prescriptions at the coffee break (with your name on) to be checked

42. Questions & Coffee Break

43. Why do we do investigations in patients with GI bleeds?
Take a minute to brainstorm for reasons for investigating patients with GI bleeds

44. Investigations - Reasons
Confirm presence of bleeding
Allow safe blood transfusion
Plan treatment
Assess degree of blood loss
Locate bleeding
Confirm suspected diagnosis
Assess extent (staging) of disease
Assess risk factors for bleeding

45. Investigations - Types
Bedside
Blood tests
Imaging
Endoscopy
Surgery
Further details of all of these in Appendix at end
Make 4 posters, bedside, blood tests, imaging, endoscopy & surgery 45

46. Case Studies – Group Work
Groups of 4-5, same colour cases
For Case 2, list and justify:
Diagnosis & 3 main differentials
Severity of Bleed
Rockall Score (pre endoscopy) if appropriate
Investigations & Management
Make flip chart
Present case afterwards
Clinical Guidelines available if desired
5-10 minutes

47. Red case 2
PC/HPC 73M
Bright red blood with dark clots in last 4 bowel motions (all today)
Mixed with stool (liquid) initially, now only blood
No abdominal pain
PMH – nil
Drugs – Movicol 1-2 satchets PRN
O/E BP 130/70 (no postural drop), P85, Hb 10.2
Abdomen soft, non tender
PR – Bright red blood plus darker clots+ in rectum

48. Case Red 2 Diagnosis Severity Rockall Score Ix and Mx
Diverticular bleed
Severity
moderate (neither mild nor severe)
Rockall Score
n/a – only for upper GI bleeds
Ix and Mx
ABCDE resuscitation
Bloods (Hb level, exclude infection),?CT abdo, Flexi sig once settled
Observe, ?antibiotics

49. Treatment – Lower GI Bleeds
Haemostasis
Most stop spontaneously +/- medical management
Angiogram Embolisation
Occasionally surgery
Generalised colonic bleeds (eg colitis)
Endoscopy rarely
Can’t see clearly

50. Treatment of underlying disease
Eg definitive treatment of
Cancers
Ulcers
Diverticular disease
.....
Conservative, Medical or Surgical
Urgent or Elective

51. Diverticular Disease
Main lumen and false lumen 51

52. Diverticular Disease Hx Ex Prone to constipation
Loose motion, then blood mixed in, then only blood
Often out of the blue
Known diverticular disease Ex
Abdomen usually non tender
Blood PR, no masses, no anorectal pathology

53. Inflammatory Bowel DiseaseHx
Known IBD
Loose motions, up to 20x/day
Now mucus and blood, increased frequency Ex
Thin
Tender abdomen
Systemic signs of IBD

54. Ulcerative Colitis

55. Crohn’s Disease

56. Yellow 2
PC/HPC 70 F
24hrs increasing generalised abdo pain (now severe++) and diarrhoea
Now blood mixed with stools, bright and dark red
PMH AF, otherwise well
O/E Pulse 130 Ireg Ireg, BP 110/60 lying, 90/50 sitting,
RR 24, looks pale and clammy,
Abdomen soft, no localised tenderness
PR – blood mixed with mucus and liquid stool on finger
ABG – Lactate 5.1, pO2 12.4, pCO2 3.0, pH 7.35

57. Case Yellow 2 Diagnosis Severity Rockall Score Ix and Mx
Ischemic colitis
Severity
Severe
Rockall Score
n/a
Ix and Mx
ABCDE resuscitation
ECG, Rigid sigi, Bloods (Hb, Trop I, U&Es, inflammatory markers), CT abdo, Colonoscopy
NBM, IVI, Antibiotics, +/- Surgery

58. Ischemic Colitis Hx Ex AF / IHD Generalised pain Colitic symptoms
Very unwell Ex
“pain out of proportion with signs”
No localised signs (until perforation)
Acidosis

59. Case Blue 2 PC/HPC 45 M attends A&E
3 episodes haematemesis today, bright red blood++
no other complaints from patient
PMH – admits nil
SH – 4 cans strong larger / day
Drugs – Thiamine, Vit B Co Strong
O/E HR 110bpm reg, BP 98/60
mildly confused (GCS 14/15)
Jaundiced, 3x spider nevi on chest and abdomen
Abdomen soft, non tender. RUQ tender mass, smooth, 1 finger breath below costal margin, moves with respiration
PR – Dark red blood in rectum, no visible stools

60. Case Blue 2 Diagnosis Severity Rockall Score Ix and Mx
Bleeding Varacies
Severity
Severe
Rockall Score
Age 0, Shock 2, Co-morbidity 3 = Total 5
Ix and Mx
ABCDE resucitation, inc up to 2l fluids, FFP, ? blood
Terlipressin, Tazocin, ?Vitamin K, Urgent senior r/v, urgent endoscopy

61. Rockall Score (Upper GI only)
Pre endoscopy 5
Variable 1 2 3
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
Co-morbidity
No major cormorbidity
CCF, IHD, major comorbidity
Renal failure, liver failure, malignancy
Diagnosis
(Post OGD)
Mallory-Weiss tear, no lesion identified, no SRH
All other diagnoses
Malignancy of upper GI tract
Major stigmata of recent haemorrhage
None or dark spot only
Blood in GI tract, adherent clot, visible or spurting vessel
Pre OGD Score
0-1 next available list (Mortality <2.5%)
>=2 urgent OGD (Mortality 5%)
Post OGD Score
<3 good prognosis, early discharge
>8 high risk of death 61

62. Case Blue 2 OGD Results Post endoscopy Rockall Score Outcome
Large oesophageal varices, no active bleeding. Clots in stomach. Varices banded.
Post endoscopy Rockall Score
Diagnosis 1, SRH 2 Total 8
Outcome
High risk of death, needs close monitoring (e.g. HDU / ITU)

63. Rockall Score (Upper GI only)
Post endoscopy 8
Variable 1 2 3
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
Co-morbidity
No major cormorbidity
CCF, IHD, major comorbidity
Renal failure, liver failure, malignancy
Diagnosis
(Post OGD)
Mallory-Weiss tear, no lesion identified, no SRH
All other diagnoses
Malignancy of upper GI tract
Major stigmata of recent haemorrhage
None or dark spot only
Blood in GI tract, adherent clot, visible or spurting vessel
Pre OGD Score
0-1 next available list (Mortality <2.5%)
>=2 urgent OGD (Mortality 5%)
Post OGD Score
<3 good prognosis, early discharge
>8 high risk of death 63

64. Oesophagael Varices
Looks like varicose veins of the legs! 64

65. Varices Hx Ex Known liver disease Known varices High alcohol intake
Stigmata of liver disease
Smell of alcohol on breath

66. Yellow sclera

67. Caput Medusae

68. Man with gynaecomastia

69. Palmar erythema

70. Dupuytren’s contracture

71. Case Green 2 PC/HPC 35M, GP admission to CDU
Diarrhoea today, and feeling a little faint at times, but hasn’t passed out. Mild epigastric pain 1/7, settles with antacids.
PMH – Sports injury 10/7 ago, ?ACL damage
Drugs – nil regular, on pain relief for knee
Allergies - nil
O/E Pulse 100 reg, BP 110/60, (lying), 80/40 (standing)
Tender epigastrium, no guarding, stomach slightly bloated, no organomegaly
PR – black, tarry motion, no red blood
Other examination normal

72. Case Green 2 Diagnosis Severity Rockall Score Ix and Mx Duodenal Ulcer
Severe
Rockall Score
Age 0, Shock 2, Co-morbidity 0= Total 2
Ix and Mx
ABCDE, 2L fluids, +/- blood
IV Omeprazole, endoscopy within 24hrs, close monitoring, ?Erect CXR (exclude perf)

73. Case Green 2 Results Post endoscopy Rockall Score
OGD after 2hrs (pt deteriorated) – Blood in stomach ++, large duodenal ulcer, spurting blood
Post endoscopy Rockall Score
Diagnosis 1, SRH 2, Total 5

74. Rockall Score (Upper GI only)
Post endoscopy score 5
Variable 1 2 3
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
Co-morbidity
No major cormorbidity
CCF, IHD, major comorbidity
Renal failure, liver failure, malignancy
Diagnosis
(Post OGD)
Mallory-Weiss tear, no lesion identified, no SRH
All other diagnoses
Malignancy of upper GI tract
Major stigmata of recent haemorrhage
None or dark spot only
Blood in GI tract, adherent clot, visible or spurting vessel
Pre OGD Score
0-1 next available list (Mortality <2.5%)
>=2 urgent OGD (Mortality 5%)
Post OGD Score
<3 good prognosis, early discharge
>8 high risk of death 74

75. Gastric and Duodenal Ulcers

76. Gastritis
Same causes as ulcer. Diffuse. Oozes blood rather than catastrophic haemorrage. 76

77. Peptic ulcers and ErosionsHx
Associated with typical pain
NSAID use
Previous gastritis / ulcers
Stress (including operations) Ex
Epigastric tenderness / guarding

78. Perforated ulcers Ulcers rarely bleed and perforate simultaneously
Suspect perforation if any abdominal guarding
Localised epigastric guarding
Generalised peritonitis
If suspicious
get Erect CXR
Surgical input

79. Post op Complications Rare ++++++
Must be considered if recent intervention
More commonly, re-bleeds post haemostaic interventions
Can be very large bleeds, clots+++

80. Dieulafoy’s lesion AV malformation Very difficult to see at endoscopy
Frequently re-bleeds after intervention
Can be missed, so can bleed after “negative” endoscopy

81. Case 3
PC/HPC 48F, 1/12 increasing “heartburn”, associated with weight loss (2/12), loss of appetite (2-3/52), and being “off colour”. Bowels unchanged
Hb 6.0 MCV 74 (normal ) at GP today, causing admission (last Hb 1 ½ yrs ago 12.5)
PMH –normal OGD 2/52 ago, to Ix indigestion ?awaiting further tests
Normally fit and well
O/E – Pale, thin. Pulse 90, BP 140/85 (no postural drop)

82. ECG

83. Case 3
PC/HPC 48F, 1/12 increasing “heartburn”, associated with weight loss (2/12), loss of appetite (2-3/52), and being “off colour”. Bowels unchanged
Hb 6.0 MCV 74 (normal ) at GP today, causing admission (last Hb 1 ½ yrs ago 12.5)
PMH –normal OGD 2/52 ago, to Ix indigestion ?awaiting further tests
Normally fit and well
O/E – Pale, thin. Pulse 90, BP 140/85 (no postural drop)
ECG immediately after arrival - ST depression
Abdomen - Vague Mass RIF, non tender
PR – soft brown stool on examining finger.

84. Case 3 Diagnosis Severity Ix and Mx
Angina caused by anaemia, secondary to cecal carcinoma
Severity
Bleed is not acute but chronic, so n/a
Ix and Mx
Treat angina (GTN spray), consider ACS
Slow transfusion, +/- diuretic, as at risk of overload (not acute blood loss, plus cardiac symptoms)
CT scan +/- colonoscopy to confirm diagnosis
Definitive treatment for cancer (Right Hemicolectomy)

85. Colon Cancer

86. Colorectal MalignancyHx
Weigh loss, loss of appetite, lethargy
Right sided – often only iron deficiency anaemia
Left side – change in bowel habit, blood mixed with stool, mucus Ex
Palpable mass (abdominal / PR)
Visible weight loss
Craggy liver edge
May be normal

87. Gastric Cancer
Gastric malignancy. What makes it look malignant? 87

88. Oesophageal cancer
Craggy, irregular appearance on one side, smooth on the other. 88

89. Features of Upper GI cancers
1 minute, work in pairs
Discuss features of history and examination that suggest upper GI malignancy as cause for bleed
List
3 features on history
3 findings on examination

90. Oesophageal & Gastric MalignanciesHx
Weight loss, loss of appetite, general lethargy
Dysphagia
Known malignancy
Recent stent insertion Ex
Emaciated
Palpable craggy liver edge
Palpable neck LN (rare)
Visible mets (rare)

91. Summary (1) Colour of blood important for location of bleed
Assess severity of bleed (including Rockall Score) to decide urgency of management
Simultaneous Resuscitation, Investigations & Management if unwell
Targeted investigations for less sick patients

92. Summary (2) Likely diagnosis from history and examination
Working diagnosis to guide management
Use guidelines / pathways to aid management
ASK FOR HELP when needed!!!

93. Any Questions?

94. Appendix – Investigations for GI bleed patients

95. Bedside Fecal Ocult Blood (FOB) Proctoscopy Rigid Sigmoidoscopy
Not commonly available now as bedside test
Still used in lab for bowel cancer screening
Proctoscopy
Anal canal
Rigid Sigmoidoscopy
Rectum and distal sigmoid colon
Up to 20cm max

96. Blood tests FBC LFTs & Clotting Tumour Markers G&S / Crossmatch
Hb level
? Chronic microcytic anaemia
LFTs & Clotting
Clotting disorders and risk factors for these
Liver failure, and risk of varacies
Tumour Markers
CEA if suspected colon cancer
Ca19.9, Ca125 & CEA if suspected gastric cancer
G&S / Crossmatch
Allows transfusion

97. Imaging - location of bleed
All during active bleed
CT Angiogram
Non invasive, sensitivity & specificity 85-90%
Angiogram
Bleeds >0.5 ml/min
Therapeutic & diagnostic
Red Cell Scan - Tc-99m RBC scintigraphy
Slow volume bleeds, >0.1ml/min

98. CT Angiogram
Figure 1c.  Active sigmoid bleeding in a 94-year-old woman who presented with bright red blood from the rectum. (a, b) Axial (a) and coronal (b) CT angiograms demonstrate active contrast material extravasation into the sigmoid colon (arrow). Note the multiple colonic diverticuli in this region and the contrast material–filled diverticulum that is optimally demonstrated on the coronal image, presumably representing the site of hemorrhage. (c) Findings on an IMA angiogram confirm the presence of active sigmoid bleeding (arrowheads). The patient was treated successfully with coil embolization.
Laing C J et al. Radiographics 2007;27:
©2007 by Radiological Society of North America

99. Imaging – cause of bleed
CT abdomen & pelvis with contrast
Acutely unwell, for cause including ?colitis
Staging suspected cancers
Barium Enema
Diverticular disease, Colon Cancer
CT Colon
As for Ba Enema
Barium meal / follow-through
Investigate possible small bowel causes (Chron’s)

100. Transverse CT image
56-year-old man with pseudomembranous colitis who was undergoing antibiotic treatment for endocarditis. In the sigmoid colon, a shaggy thickened bowel wall with alternating areas of necrosis (arrows) and plaques is visible

101. Endoscopy Rigid scopes – see bedside tests
OGD (Oesophago-gastro-duodenoscopy, Gastroscopy, Upper GI endoscopy)
For all Upper GI bleeds
Flexible Sigmoidoscopy
Suspected left sided colonic bleeds
To splenic flexure, aprox 40-60cm
Colonoscopy
Suspected right sided colonic bleeds
Whole colon visualised
Flexi Sig and Colon – not in bleeding patients
Poor vision – risk of perforation

102. Surgery
Last resort
When location not found, and ongoing significant bleed
Can locate most proximal part of bowel with blood in lumen, & Limited resection
If unclear, and colonic, occasionally total colectomy