1. Gastrointestinal Haemorrhage
Pre Lecture Handout

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 Attitudes
Know what colours are likely to represent blood in a vomit or stool sample
Understand why blood changes colour in the GI tract
Understand resuscitation of bleeding patient, including use of fluids and blood
List common causes of GI bleeds
Know symptom complexes that clinically differentiate these causes
Think about different types of investigations and what information can be obtained from them
Attitudes
Appreciate knowing purpose of investigations allows correct choice of investigation

4. Outline Recognising GI Bleeds Causes of GI Bleeds
Features of specific Lower GI Bleeds
Investigation of Lower GI Bleeds
Upper GI Bleeds in Case studies in week 5

5. 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

6. Colours of Blood
List different colours blood may be in vomit or stool

7. 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

8. 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

9. 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

10. 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

11. Case 1
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

12. 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

13. 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

14. Case 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

15. 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

16. 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

17. 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 (mild) diffusely
Abdomen - Vague Mass RIF, non tender
PR – soft brown stool on examining finger.

18. 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

19. Management Resuscitation Investigations to confirm cause of bleed
Specific treatment of cause
Investigations may be IP or OP

20. Resuscitation
Airway
Breathing
Circulation
Disability
Exposure

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

22. 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
Fluid challenge, if shocked 2L warmed crystalloid
If continued shock: blood, clotting factors
Urinary catheter
Cross match at least six units for bleeding varices. 22

23. 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

24. 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

25. 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)

26. Low risk patients
Consider for discharge or non-admission with outpatient follow-up if:
Age < 60, and;
No evidence of haemodynamic disturbance, and;
No evidence of gross rectal bleeding, and;
An obvious anorectal source of bleeding on rectal examination +/- rigid sigmoidoscopy.

27. 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

28. Investigations - Types
Bedside
Blood tests
Imaging
Endoscopy
Surgery
Make 4 posters, bedside, blood tests, imaging, endoscopy & surgery

29. Treatment Haemostasis Treatment of underlying disease
Most stop spontaneously +/- medical managment
Angiogram Embolisation
Occasionally surgery
Generalised colonic bleeds (eg colitis)
Endoscopy rarely
Treatment of underlying disease
Medical or Surgical
Urgent or Elecitve

30. Summary Colour of blood important for location of bleed
ABCDE resuscitation
Likely diagnosis from history and examination
Targeted investigations
Allows
Planning of treatment
Priorities