Gastrointestinal Haemorrhage Mrs Esther Mitchell Clinical Teaching Fellow

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

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

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

Outline Patient Pathways General principles & Worked Examples Recognising a GI Bleed Causes of GI Bleeds Management Investigations Including Case Study Group work sessions

Patient Pathway – “Normal” Treatment Presentation History & Examination Provisional Diagnosis Investigations Specific Diagnosis

Patient Pathway – “Acute” Presentation Unstable Patient Specific Treatment Stable Patient Further Investigations Confirm Diagnosis Resuscitation Haemostasis Medical Management Investigations History & Examination Working Diagnosis

Recognise a GI Bleed

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

Colours of Blood Colour Vomit Stool Bright Red √ Dark Red x Green Black Brown x ? No motion / vomit ?

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

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

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

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

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% Mallory Weiss is a laceration at the junction of the oesophagus and stomach, due to forceful coughing or vomiting.

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 Angiodysplasia – vascular malformation, often small but multiple, causing subtle symptoms. Ischaemic colitis – usually elderly people, cause for ischaemia generally unknown but can be embolic.

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

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

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)

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)

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!!!

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

Case 1 Diagnosis Severity Rockall Score Ix and Mx Mallory Weiss tear Mild Rockall Score Age 0, Shock 0, co-morbidity 0 = 0 Ix and Mx Senior r/v with view to discharge and OP OGD

Rockall Score (Upper GI only) Variable 1 2 3 Age <60 years 60-79 years >80 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 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 24

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

Mallory Weiss tear

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

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

Anal Fissure

Haemorrhoids

Fistula in aino

Moderate & Sever Bleeds

Resuscitation Airway Breathing Circulation Disability Exposure

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 34

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

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 Cross match at least six units for bleeding varices. 36

Blood

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

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 at rate of 150 mls/min

Medical Management Stop Give Consider 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

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

Questions & Coffee Break

Why do we do investigations in patients with GI bleeds? Take a minute to brainstorm for reasons for investigating patients with GI bleeds

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

Investigations - Types Bedside Blood tests Imaging Endoscopy Surgery Further details of all of these in Appendix at end Make 4 posters, bedside, blood tests, imaging, endoscopy & surgery 45

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

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

Case Red 2 Diagnosis Severity Rockall Score Ix and Mx 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

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

Treatment of underlying disease Eg definitive treatment of Cancers Ulcers Diverticular disease ..... Conservative, Medical or Surgical Urgent or Elective

Diverticular Disease Main lumen and false lumen 51

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

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

Ulcerative Colitis

Crohn’s Disease

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

Case Yellow 2 Diagnosis Severity Rockall Score Ix and Mx 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

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

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

Case Blue 2 Diagnosis Severity Rockall Score Ix and Mx 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

Rockall Score (Upper GI only) Pre endoscopy 5 Variable 1 2 3 Age <60 years 60-79 years >80 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 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 61

Case Blue 2 OGD Results Post endoscopy Rockall Score Outcome 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)

Rockall Score (Upper GI only) Post endoscopy 8 Variable 1 2 3 Age <60 years 60-79 years >80 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 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 63

Oesophagael Varices Looks like varicose veins of the legs! 64

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

Yellow sclera

Caput Medusae

Man with gynaecomastia

Palmar erythema

Dupuytren’s contracture

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

Case Green 2 Diagnosis Severity Rockall Score Ix and Mx Duodenal Ulcer 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)

Case Green 2 Results Post endoscopy Rockall Score OGD after 2hrs (pt deteriorated) – Blood in stomach ++, large duodenal ulcer, spurting blood Post endoscopy Rockall Score Diagnosis 1, SRH 2, Total 5

Rockall Score (Upper GI only) Post endoscopy score 5 Variable 1 2 3 Age <60 years 60-79 years >80 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 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 74

Gastric and Duodenal Ulcers

Gastritis Same causes as ulcer. Diffuse. Oozes blood rather than catastrophic haemorrage. 76

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

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

Post op Complications Rare ++++++ Must be considered if recent intervention More commonly, re-bleeds post haemostaic interventions Can be very large bleeds, clots+++

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

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 80-100) 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

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 80-100) 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.

Case 3 Diagnosis Severity Ix and Mx 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)

Colon Cancer

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

Gastric Cancer Gastric malignancy. What makes it look malignant? 87

Oesophageal cancer Craggy, irregular appearance on one side, smooth on the other. 88

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

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)

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

Summary (2) Likely diagnosis from history and examination Working diagnosis to guide management Use guidelines / pathways to aid management ASK FOR HELP when needed!!!

Any Questions?

Appendix – Investigations for GI bleed patients

Bedside Fecal Ocult Blood (FOB) Proctoscopy Rigid Sigmoidoscopy 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

Blood tests FBC LFTs & Clotting Tumour Markers G&S / Crossmatch 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

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

CT Angiogram Figure 1c.  Active sigmoid bleeding in a 94-year-old woman who presented with bright red blood from the rectum. (a, b) Axial (a) and coronal (b) CT angiograms demonstrate active contrast material extravasation into the sigmoid colon (arrow). Note the multiple colonic diverticuli in this region and the contrast material–filled diverticulum that is optimally demonstrated on the coronal image, presumably representing the site of hemorrhage. (c) Findings on an IMA angiogram confirm the presence of active sigmoid bleeding (arrowheads). The patient was treated successfully with coil embolization. Laing C J et al. Radiographics 2007;27:1055-1070 ©2007 by Radiological Society of North America

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)

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

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

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