Gastrointestinal Haemorrhage Pre Lecture Handout

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 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

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

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 List different colours blood may be in vomit or stool

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

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

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

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

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

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

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

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

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

Resuscitation Airway Breathing Circulation Disability Exposure

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 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

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

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, and; No evidence of gross rectal bleeding, and; An obvious anorectal source of bleeding on rectal examination +/- rigid sigmoidoscopy.

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 Make 4 posters, bedside, blood tests, imaging, endoscopy & surgery

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

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