Mohammad Mobasheri SpR General Surgery GI Bleed Mohammad Mobasheri SpR General Surgery

GI Bleeding Maybe classified into: Upper GI bleeding (proximal to DJ flexure) Variceal bleeding Non-variceal bleeding Lower GI bleeding (distal to DJ flexure) Upper GI bleeding 4x more common than lower GI bleeding Emergency resuscitation same for upper and lower GI bleeds

Emegency Resuscitation Takes priority over determining the diagnosis/cause ABC (main focus is ‘C’) Oxygen: 15L Non-rebreath mask 2 large bore cannulae into both ante-cubital fossae Take bloods at same time for FBC, U&E, LFT, Clotting, X match 6Units Catheterise IVF initially then blood as soon as available (depending on urgency: O-, Group specific, fully X-matched) Monitor response to resuscitation frequently (HR, BP, urine output, level of consciousness, peripheral temperature, CRT) Stop anti-coagulants and correct any clotting derrangement NG tube and aspiration (will help differentiate upper from lower GI bleed) Organise definitive treatment (endoscopic/radiological/surgical)

Estimating Degree of Blood Loss RR, HR, and BP can be used to estimate degree of blood loss/hypovolaemia Class I Class II Class III Class IV Volume Loss (ml) 0-750 750-1500 1500-2000 >2000 Loss (%) 0-15 15-30 30-40 >40 RR 14-20 20-30 HR <100 >100 >120 >140 BP Unchanged Reduced Urine Output (ml/hr) >30 5-15 Anuric Mental State Restless Anxious Anxious/confused Confused/ lethargic

History and Examination Aim of history and examination is 3 fold 1. Identify likely source – upper vs lower – and potential cause 2. Determine severity of bleeding 3. Identify precipitants (e.g. Drugs)

History in patients with GI bleeding PC/HPC Duration, frequency, and volume of bleeding (indicate severity of bleeding) Nature of bleeding: will point to source Haematemesis (fresh or coffee ground)/melaena suggest upper GI bleed. (Note a very brisk upper GI bleed can present with dark or bright red blood PR). PR Dark red blood suggests colon PR Bright red blood suggests rectum, anus If PR bleeding, is blood being passed alone or with bowel opening (if alone suggests heavier bleeding) If with bowel opening is blood mixed with the stool (colonic), coating the stool (colonic/rectal), in the toilet water (anal), on wiping (anal) Ask about associated upper or lower GI symptoms that may point to underlying cause E.g. Upper abdominal pain/dyspeptic symptoms suggest upper GI cause such as peptic ulcer E.g. 2. lower abdo pain, bowel symptoms such as diarrhoea or a background of change in bowel habit suggest lower GI cause e.g. Colitis, cancer Previous episodes of bleeding and cause PMH History of any diseases that can result in GI bleeding, e.g. Peptic ulcer disease, diverticular disease, liver disease/cirrhosis Bleeding disorders e.g. haemophilia DH Anti-platelets or anti-coagulants can exacerbate bleeding NSAIDs and steroids may point to PUD SH Alcoholics at risk of liver disease and possible variceal bleeding as a result Smokers at risk of peptic ulcer disease

Examination in patients with GI bleeding Reduced level of consiousness Pale and clammy Cool peripheries Reduced CRT Tachcardic and thready pulse Hypotensive with narrow pulse pressure Tenderness on abdominal examination may point to underlying cause e.g. Epigastric  peptic ulcer Stigmata of chronic liver disease (palmer erythema, leukonychia, dupuytrens contracture, liver flap, jaundice, spider naevi, gynacomastia, shifting dullness/ascites) Digital rectal examination may reveal melaena, dark red blood, bright red blood

Upper GI bleed

Upper GI bleed Upper GI bleeding refers to bleeding from oesophagus, stomach, duodenum (i.e. Proximal to ligmanet of treitz) Bleeding from jejunum/ileum is not common

Presentation Acute Upper GI bleeding presents as: Haematemesis (vomiting of fresh blood) Coffee ground vomit (partially digested blood) Melaena (black tarry stools PR) If bleeding very brisk and severe then can present with red blood PR! If bleeding very slow and occult then can present with iron deficiency anaemia

Causes Cause of Bleeding Relative Frequency Peptic Ulcer 44 Oesophagitis 28 Gastritis/erosions 26 Duodenitis 15 Varices 13 Portal hypertensive gastropathy 7 Malignancy 5 Mallory Weiss tear Vascular Malformation 3 Other (e.g. Aortoenteric fistula) rare

Risk Stratification: Rockall Score Identifies patients at risk of adverse outcome following acute upper GI bleed Score <3 carries good prognosis Score >8 carries high risk of mortality Variable Score 0 Score 1 Score 2 Score 3 Age <60 60-79 >80 - Shock Nil HR >100 SBP <100 Co-morbidity Nil major IHD/CCF/major morbidity Renal failure/liver failure Diagnosis Mallory Weiss tear All other diagnoses GI malignancy Endoscopic Findings None Blood, adherent clot, spurting vessel

Management (Non-variceal) Emergency resuscitation as already described Endoscopy Urgent OGD (within 24hrs) – diagnostic and therepeutic Treatment administered if active bleeding, visible vessel, adherent blood clot Treatment options include injection (adrenaline), coagulation, clipping If re-bleeds then arrange urgent repeat OGD Pharmacology PPI (infusion) – pH >6 stabilises clots and reduces risk of re-bleeding following endoscopic haemostasis Tranexamic acid (anti-fibrinolytic) – maybe of benefit (more studies needed) If H pylori positive then for eradication therapy Stop NSAIDs/aspirin/clopidogrel/warfarin/steroids if safe to do so (risk:benefit analysis)

Management (Non-variceal) Surgery Reserved for patients with failed medical management (ongoing bleeding despite 2x OGD) Nature of operation depends on cause of bleeding (most commonly performed in context of bleeding peptic ulcer: DU>GU) E.g. Under-running of ulcer (bleeding DU), wedge excision of bleeding lesion (e.g. GU), partial/total gastrectomy (malignancy)

Variceal Bleeds Suspect if upper GI bleed in patient with history of chronic liver disease/cirrhosis or stigmata on clinical examination Liver Cirrhosis results in portal hypertension and development of porto-systemic anastamosis (opening or dilatation of pre-existing vascular channels connecting portal and systemic circulations) Sites of porto-systemic anastamosis include: Oesophagus (P= eosophageal branch of L gastric v, S= oesophageal branch of azygous v) Umbilicus (P= para-umbilical v, S= infeior epigastric v) Retroperitoneal (P= right/middle/left colic v, S= renal/supra-renal/gonadal v) Rectal (P= superior rectal v, S= middle/inferior rectal v) Furthermore, clotting derrangement in those with chronic liver disease can worsen bleeding

Management of Variceal bleeds Emergency resuscitation as already described Drugs Somatostatin/octreotide – vasoconstricts splanchnic circulation and reduces pressure in portal system Terlipressin – vasoconstricts splanchnic circulation and reduces pressure in portal system Propanolol – used only in context of primary prevention (in those found to have varices to reduce risk of first bleed) Endoscopy Band ligation Injection sclerotherapy Balloon tamponade – sengstaken-blakemore tube Rarely used now and usually only as temporary measure if failed endoscopic management Radiological procedure – used if failed medical/endoscopic Mx Selective catheterisation and embolisation of vessels feeding the varices TIPSS procedure: transjugular intrahepatic porto-systemic shunt shunt between hepatic vein and portal vein branch to reduce portal pressure and bleeding from varices): performed if failed medical and endoscopic management Can worsen hepatic encephalopathy Surgical Surgical porto-systemic shunts (often spleno-renal) Liver transplantation (patients often given TIPP/surgical shunt whilst awaiting this)

TIPSS Sengstaken-Blakemore Tube

Surgical porto-systemic shunt (spleno-renal shunt)

Variceal Bleed: Prognosis Prognosis closely related to severity of underlying chronic liver disease (Childs-Pugh grading) Child-Pugh classification grades severity of liver disease into A,B,C based on degree of ascites, encephalopathy, bilirubin, albumin, INR Mortality 32% Childs A, 46% Childs B, 79% Childs C

Lower GI Bleed

Lower GI bleeding Lower GI bleed refers to bleeding arising distal to the ligament of Treitz (DJ flexure) Although this includes jejunum and ileum bleeding from these sites is rare (<5%) Vast majority of lower GI bleeding arises from colon/rectum/anus

Presentation Lower GI bleeding presents as: Dark red blood PR – more proximal bleeding point (e.g. Distal small bowel, colon) Bright red blood PR – more distal bleeding point (e.g. rectum, anus) PR blood maybe: mixed or separate from the stool If separate from the stool it maybe noticed in the toilet water or on wiping Passed with motion or alone If blood mixed with stool (as oppose to separate from it) suggests more proximal bleeding If bleeding very slow and occult then can present with iron deficiency anaemia

Causes Colon Rectum Anus Diverticular Disease Polyps Haemorrhoids Malignancy Fissure Proctitis Colitis Angiodysplasia

Management Emergency resuscitation as already described Pharmacological Stop NSAIDS/anti-platelets/anti-coagulants if safe Tranexamic acid Endoscopic OGD (15% of patients with severe acute PR bleeding will have an upper GI source!) Colonoscopy – diagnostic and therepeutic (injection, diathermy, clipping)

Management Radiological CT angiogram – diagnostic only (non-invasive) Determines site and cause of bleeding Mesenteric Angiogram – diagnostic and therepeutic (but invasive) Determines site of bleeding and allows embolisation of bleeding vessel Can result in colonic ischaemia Nuclear Scintigraphy – technetium labelled red blood cells: diagnostic only Determines site of bleeding only (not cause)

Management Surgical – Last resort in management as very difficult to determine bleeding point at laparotomy Segmental colectomy – where site of bleeding is known Subtotal colectomy – where site of bleeding unclear Beware of small bowel bleeding – always embarassing when bleeding continues after large bowel removed!

Management Flow Chart for Severe lower GI bleeding Resuscitate OGD (to exclude upper GI cause for severe PR bleeding) Colonoscopy (to identify site and cause of bleeding and to treat bleeding by injection/diathermy/clipping) – often unsuccesful as blood obscures views CT angiogram (to identify site and cause of bleeding) Mesenteric angiogram (to identify site of bleeding and treat bleeding by embolisation of vessel) Surgery

Management As 85% of lower GI bleeds will settle spontaneously the interventions mentioned on previous slide are reserved for: Severe/Life threatening bleeds In the 85% where bleeding settles spontaneously OPD investigation is required to determine underlying cause: Endoscopy: flexible sigmoidoscopy, colonoscopy Barium enema

Iron Deficiency Anaemia

Definition Insufficient iron in the body for haemopoeisis Decrease Hb and MCV Decreased serum iron and Ferritin Increased TIBC and serum transferrin

Causes Increased Iron demand Insufficient Iron intake Chronic Blood loss Think Chronic bleeding (often occult) from GI tract in men and post-menopausal females (pre-menopause menorrhagia most common cause) e.g. Colonic polyp or cancer, gastric/duodenal ulcer or malignancy Chronic haemolysis Pregnancy Insufficient Iron intake Diet lacking in iron Vegans – plant based iron poorly absorbed compared to meat based iron Malabsorption of iron Small intestinal disease e.g. Crohn’s, caeliac disease Lack of vitamin C (important for iron absorption)

Causes In adults >50yrs of age the most common cause of Iron deficiency anaemia is chronic occult GI bleeding In females <50yrs most common cause is blood loss during menses with inadequate replacement In developing world intestinal parasitic infection causing chronic blood loss from the GI tract is the most common cause of iron deficiency anaemia (rare in developed world)

Investigations To confirm iron deficiency anaemia OGD and colonoscopy Hb, MCV, Ferritin, transferrin, TIBC Rarely bone marrow aspirate (gold standard but invasive: rarely performed) OGD and colonoscopy Perform in males and post-menopausal females In pre-menopausal females menorrhagia is most common cause and often OGD/colonoscopy not required unless other symptoms warrant it (e.g. dyspepsia, dysphagia, PR bleeding, change in bowel habit, family history etc.) Note that iron deficiency anaemia maybe the only sign of an occult GI malignancy

The End Questions