Gastrointestinal Haemorrhage

1
Gastrointestinal Haemorrhage

• Rebecca Shields
• Clinical Teaching Fellow
• UHCW

2
Acute Block Objectives - Outline

• GI Bleeds
• Explain the likely causes of upper GI bleeds from
  history and examination.
• Demonstrate an understanding of initial
  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 unwell patient
• Resuscitation

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Recognise a GI Bleed
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History

• Amount
• Difficult
• Usually under estimated
• Appearance
• What colours can blood be?
• Why does it change colour?
• Duration
• Associated Sx
• Risk factors

5
Blood loss exercise

• Estimate the volume of blood loss in each picture
• What colour can blood be?
• Why does it change?
• Always visible?

6
Colours of Blood
Colour Vomit Stool
Bright Red v v
Dark Red x v
Green x x
Black x v
Brown v x ?
No motion / vomit ? ?
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Why does blood change colour?

• Stomach Acid
• Bright Red ? brown / coffee ground
• Small Bowel Digestive enzymes
• Bright Red ? Dark Red
• Colon Bacteria
• Bright Red ? Dark Red ? Black

8
PR Bleeds (haematochezia)

• Upper GI
• Black, Tar-like (Malaena)
• Caecum / Transverse colon
• Dark Red, Loose stools
• Mixed with stools
• Sigmoid / Anus / Rectum
• Bright red
• Mixed or separate
• Massive upper GI bleed

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Consider occult GI blood loss when

• Unexplained anaemia
• Sudden hypotension and tachycardia, often fluid
  responsive
• Shocked patient - PMH of GI bleeds or risk factors

10
Urgency of Management

• Severe bleeds
• Resuscitation
• IP investigation /- treatment
• Moderate bleeds
• IP observation until bleed stops
• Often OP investigation /- treatment
• Mild / low risk bleeds
• Early discharge
• OP investigation /- treatment

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Severe Bleeds

• Severe / significant bleed if any of the
  following
• Tachycardia gt100
• Systolic BP lt100 (prior to fluid resuscitation)
• Postural hypotension
• Symptoms of dizziness
• Decreasing urine output
• Evidence of recurrent melaena / haematemesis / PR
  bleeding (haematochezia)

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Resuscitation

• Assess for signs of hypovolaemic shock
• AB
• Large clots can block airway
• Risk of aspiration
• O2 15l
• Attach monitoring

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Circulation - Interventions

• 2 large bore IV cannulae (14 or 16 G)
• Send blood for FBC, clotting, GS or X-match,
  inform blood bank
• IV fluids to maintain BPgt100 systolic
• Start with up to 2l 0.9 Sodium Chloride STAT
• Then progress to blood
• IV FFP if variceal bleed suspected or INRgt1.3
• Urinary catheter

14

• D
• E

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Blood
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Blood

• 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

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Massive Haemorrhage Protocol

• 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

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Medical Management

• Stop
• Antihypertensives
• NSAIDS
• Anticoagulants
• Give
• 10mg IV vitamin K if INR gt1.3
• Consider
• 2mg IV Terlipressin (stat then QDS)
• Broad spectrum antibiotics (e.g. Tazocin 4.5g
  tds)
• 40mg IV Omeprazole bd
• 40mg oral Omeprazole od

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Prescribing exercise

• Emma Smith unstable in AE resus with a massive
  upper GI bleed
• DOB 01/07/55
• Hospital Number AA111000
• 5 Carrington Close
• Coventry
• Prescribe
• 3units red cells

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Causes of GI Bleed

• 3 tasks!
• Brainstorm all causes of GI bleeds
• Divide into Upper Lower GI causes
• Rank from most common to least common

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Causes - Upper GI (80)

• Peptic ulcer disease 50
• Erosive Gastritis / Oesophagitis 18
• Varices 10
• Mallory Weiss tear 10
• Cancer Oesophageal or Gastric 6
• Coagulation disorders
• Other
• Aorto-enteric fistula
• Benign tumours
• Congenital Ehlers-Danlos, Osler-Weber-Rendu

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Causes - Lower GI (20)

• Upper GI bleed!
• Diverticular disease (angiodysplasia) - 60
• Colitis (IBD ischaemic) 13
• Benign anorectal (haemorrhoids, fissures,
  fistulas) 11
• Malignancy 9
• Coagulopathy 4
• Angiodysplasia 3
• Post surgical / polypectomy

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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

24
Case 1

• Diagnosis
• Mallory Weiss tear
• Severity
• Mild
• Ix and Mx
• Senior r/v with view to discharge and OP OGD
• How can we predict mortality?

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Blatchford Score (pre endoscopy)

• Predicts need for hospital based treatment
• Score of 6 or more over 50 risk of requiring
  intervention
• Lack of subjective variables (e.g. severity of
  systemic diseases)
• Lack of a need for OGD to complete the score.
• Systolic BP
• Pulse
• Melena
• Syncope
• Coborbidity
• Urea
• Hb
• Not as good as Rockall in predicting overall
  mortality

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Rockall Score (post endoscopy)
Score Score Score Score
Variable 0 1 2 3
Age lt60 years 60-79 years gt80 years
Shock No shock Tachycardia Hypotension
Co-morbidity No major comorbidity 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
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Endoscopy Upper GI Bleeds

• Minor bleeds / unproven
• Consider OP OGD
• Moderate bleeds
• IP OGD within 24hrs
• Severe bleeds
• Urgent OGD,
• Inform Surgeons and Critical Care
• Suspected Variceal bleed
• Continued bleeding, gt4u blood to keep BP gt100
• Continuing fresh melaena / haematemesis
• Re-bleed / unstable post resuscitation
• If fails, may need emergency surgery

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Mallory Weiss tear
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Mallory Weiss tear

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

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Minor Bleeds 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 ano
• Soiling on underwear, recurrent abscesses

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Anal Fissure
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Haemorrhoids
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Fistula in ano
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Moderate Severe Bleeds

• Resuscitation including Transfusion
• Medical Management
• Haemostasis
• Treatment of underlying disease

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Investigations - Why

• 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

36
Bedside

• Faecal Occult 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

37
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
• GS / Crossmatch
• Allows transfusion

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Imaging - location of bleed

• All during active bleed
• CT Angiogram
• Non invasive, sensitivity specificity 85-90
• Angiogram
• Bleeds gt0.5 ml/min
• Therapeutic diagnostic
• Red Cell Scan - Tc-99m RBC scintigraphy
• Slow volume bleeds, gt0.1ml/min

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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 (Crohns)

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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

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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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Case Studies

• Small groups, same colour cases
• For Case 2, list and justify
• Diagnosis 2 main differentials
• Severity of Bleed
• Blatchford or Rockall Score (pre endoscopy) if
  appropriate
• Investigations Management

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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

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Case Red 2

• Diagnosis
• Diverticular bleed
• Severity
• Moderate
• Blatchford 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

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Treatment Lower GI Bleeds

• Haemostasis
• Most stop spontaneously /- medical management
• Angiogram Embolisation
• Occasionally surgery
• Generalised colonic bleeds (eg colitis)
• Endoscopy rarely
• Cant see clearly

46
Treatment of underlying disease

• Definitive treatment of
• Cancers
• Ulcers
• Diverticular disease
• Conservative, Medical or Surgical
• Urgent or Elective

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Diverticular Disease
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Diverticular Disease

• Hx
• Prone to constipation
• Loose motion, then blood mixed in, then only
  blood
• Often out of the blue
• Known history
• Ex
• Abdomen usually non tender
• Blood PR, no masses, no anorectal pathology

49
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

50
Ulcerative Colitis
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Crohns Disease
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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

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Case Yellow 2

• Diagnosis
• Ischaemic colitis
• Severity
• Severe
• Blatchford score
• n/a
• Ix and Mx
• ABCDE resuscitation
• ECG, Rigid sigmoidoscopy,
• Bloods (Hb, Trop I, UEs, inflammatory markers),
• CT abdomen
• Colonoscopy
• NBM, IVI, Antibiotics, /- Surgery

54
Ischaemic Colitis

• Hx
• AF / IHD
• Generalised pain
• Colitic symptoms
• Deteriorating rapidly
• Ex
• Pain out of proportion with signs
• No localised signs (until perforation)
• Acidosis

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Case Blue 2

• PC/HPC 45 M attends AE
• 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, Urea 6.6, Hb119g/l
• 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

56
Case Blue 2

• Diagnosis
• Bleeding varices
• Severity
• Severe
• Blatchford Score
• BP 2, P 1, Melena 1, syncope 0, Comorbidities 0,
  Urea 2, Hb 3 9
• Ix and Mx
• ABCDE resuscitation, inc up to 2l fluids, FFP, ?
  blood
• Terlipressin, IV Antibiotics, ?Vitamin K, Urgent
  senior r/v, urgent endoscopy (within 8hrs)

57
Case Blue 2

• OGD Results
• Large oesophageal varices, no active bleeding.
• Clots in stomach.
• Varices banded.
• What is the Rockall Score?

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Rockall Score
Score Post endoscopy? Score Post endoscopy? Score Post endoscopy? Score Post endoscopy?
Variable 0 1 2 3
Age lt60 years 60-79 years gt80 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 (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
lt2.5) gt2 urgent OGD (Mortality 5)
Post OGD Score lt3 good prognosis, early
discharge gt8 high risk of death
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Oesophageal Varices

• Hx
• Known liver disease
• Known varices
• High alcohol intake
• Ex
• Stigmata of liver disease
• Smell of alcohol on breath

60
Yellow sclera
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Caput Medusae
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Gynaecomastia
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Palmar erythema
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Dupuytrens contracture
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Case Green 2

• PC/HPC
• 35M, GP admission to CDU
• Diarrhoea today, and feeling a little faint at
  times, but hasnt 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 epigastrum, no guarding, slightly
  distended, no organomegaly
• PR black, tarry motion, no red blood or faeces
• Other examination normal

66
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

67
Case Green 2

• OGD after 2hrs (pt deteriorated)
• Blood in stomach
• Large duodenal ulcer, spurting blood
• What is the new Rockall Score?

68
Rockall Score (Upper GI only)
Score Post endoscopy score? Score Post endoscopy score? Score Post endoscopy score? Score Post endoscopy score?
Variable 0 1 2 3
Age lt60 years 60-79 years gt80 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 (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
lt2.5) gt2 urgent OGD (Mortality 5)
Post OGD Score lt3 good prognosis, early
discharge gt8 high risk of death
69
Gastric and Duodenal Ulcers
70
Gastritis
71
Peptic ulcers and Erosions

• Hx
• Associated with typical pain
• NSAID use
• Previous gastritis / ulcers
• Stress (including operations)
• Ex
• Epigastric tenderness / guarding

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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

73
Other Bleeds

• Post op Complications

• Dieulafoys lesion

• Very rare
• Must be considered if recent intervention
• More commonly, re-bleeds post haemostatic
  interventions
• Can be very large bleeds, clots

• AV malformation
• Very difficult to see at endoscopy
• Frequently re-bleeds after intervention
• Can be missed, so can bleed after negative
  endoscopy

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Colon Cancer
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Colorectal Malignancy

• Hx
• Weight loss, loss of appetite, lethargy
• Right sided often only iron deficiency anaemia
• Left side change in bowel habit, blood mixed
  with stool, mucus, tenesmus
• Ex
• Palpable mass (abdominal / PR)
• Visible weight loss
• Craggy liver edge
• May be normal

76
Gastric Cancer
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Oesophageal cancer
78
Oesophageal Gastric Malignancies

• Hx
• Weight loss, loss of appetite, general lethargy
• Dysphagia
• Vomiting
• Known malignancy
• Recent stent insertion
• Ex
• Emaciated
• Palpable craggy liver edge
• Palpable neck LN (rare)
• Visible metastases (rare)

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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

80
Summary (2)

• Likely diagnosis from history and examination
• Use guidelines / pathways to aid management
• ASK FOR HELP when needed!!!

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ANY QUESTIONS?