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Gastrointestinal Haemorrhage Mrs Esther Mitchell Clinical Teaching Fellow.

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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?

10 Colours of Blood ColourVomitStool Bright Red√√ Dark Redx√ Greenxx Blackx√ 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

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%

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

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

18 Urgency of Management Severe 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 Mallory Weiss tear Severity 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) Score Variable0123 Age<60 years60-79 years>80 years ShockNo shockTachycardiaHypotension Co-morbidityNo 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 (Post OGD) 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

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

28 Benign Anorectal 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

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

37 Blood

38 O Negative 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  or at rate of 150 mls/min

40 Medical Management Stop 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

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 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

52 Hx 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 Disease Hx 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 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 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 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) Score Pre endoscopy 5 Variable0123 Age<60 years60-79 years>80 years ShockNo shockTachycardiaHypotension Co-morbidityNo 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 (Post OGD) 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

62 Case Blue 2 OGD Results 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) Score Post endoscopy 8 Variable0123 Age<60 years60-79 years>80 years ShockNo shockTachycardiaHypotension Co-morbidityNo 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 (Post OGD) 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

64 Oesophagael Varices

65 Varices Hx Known liver disease Known varices High alcohol intake Ex 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 Duodenal Ulcer Severity 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 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) Score Post endoscopy score 5 Variable0123 Age<60 years60-79 years>80 years ShockNo shockTachycardiaHypotension Co-morbidityNo 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 (Post OGD) 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

75 Gastric and Duodenal Ulcers

76 Gastritis

77 Peptic ulcers and Erosions Hx 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 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 Malignancy Hx 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

88 Oesophageal cancer

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 Malignancies Hx 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) 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 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 Laing C J et al. Radiographics 2007;27: ©2007 by Radiological Society of North America CT Angiogram

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


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