1. GI Bleeding Presentations Dr Mark Putland Co-DEMT Bendigo Health Care Group

2. Case 1 68 year old male Syncope at home No obvious cause on history general examination. HR 85 (reg), BP 138/75, RR 20, SpO 2 99% 5L/min. ECG normal. Hb 130.

3. Could a GI bleed be responsible for this presentation? What sort of a bleed? Why are the obs and Hb normal? What might help us suspect GI bleed as a cause? – On history? – On examination? – On basic bloods?

4. Further history Meds: atenolol, diclofenac, aspirin, candesartan, simvastatin. No abdominal pain. Occasional dark stools over last few months.

5. Further examination PR- black stool Postural BP 138/75  110/60 JVP not visible Abdomen soft and non-tender

6. Further Bloods Urea 16, Cr 80 PvCO 2 30, pH 7.32, Bicarb 20, Lactate 2.1

7. Case 1 continued Pt was cared for by a doctor who didn’t seek the further history, exam findings or bloods above. Troponin and CT brain were normal though. After 3 hours in ED the patient stands up to go to the toilet and faints again. This time a large black tarry stool is produced.

8. What do you do with him?

9. Patient moved to resus. 2 Large bore IV inserted. More blood taken. Fluid started. HR 120, BP 105/90, RR 24, GCS 15

10. How is he looking now?

11. 2L N.Saline given. HR 100, BP 120/90, RR 24, SpO 2 98% on 8L, GCS 15 Pt begins to vomit black granular vomit.

12. What does this mean?

13. More vomiting, now red blood. HR 130, BP 95/40, RR 30, GCS 13, SpO 2 poor trace.

14. What do you do now? What definitive procedure does he need? Where can it be done? What are the pros and cons of – Endoscopy suite – Theatre – Resus How should his sedation be managed?

15. Patient is sedated with ketamine and intubated. Surgeon brings scope to resus. Blood has been delayed because no one thought they were asked to get it. 4L N.Saline have been given HR 55, BP failed to read and is cycling again, SpO 2 fallen off finger.

16. How is he now? What does he need right now?

17. Case 2 48 year old woman. Malnourished looking. Sent by RDNS because not coping at home, house squalid, patient seems confused. Small red vomit in ambulance. HR 68, BP 90/40, RR 22, drowsy and uncooperative with examination, ~50kg

18. Where might this blood be from? What historical features might we expect? – sHx – pHx – Meds What examination features might we expect? What urgent blood test must we do?

19. There are further larger red vomits in ED. HR 75, BP 80/40, remaining drowsy. What pharmacological therapies might help? What definitive therapy is required? What other supportive care is required? Where will the patient be nursed after ED discharge?

20. Hb 77, Ur 30, Cr 120, Na 110. Will knowing the ammonia change management? After 2 units PRBC, 2 units FFP and a pooled bag of platelets and with octreotide running BP is 100/50, HR 68, no further vomiting in last hour. Med reg asks you to (therapeutic) tap the ascites before admission. Is this a good idea?

21. Case 3 83 year old woman 2 sudden painless rectal bleed this morning. Patient felt faecal urgency and produced only red blood. Tired but no syncope or dizziness. Abdo exam normal apart from non-specific and inconsistent lower abdominal tenderness.

22. What past history would be useful? Where might this blood be from?

23. Diverticular disease Lower GI malignancy Angiodysplasia Haemorrhoids Massive upper GI bleed

24. What procedures or tests will help us with diagnosis? What therapeutic procedures may be required?