Gastrointestinal Haemorrhage Joel Burton Clinical Teaching Fellow UHCW.

Slides:



Advertisements
Similar presentations
Management of acute upper GI haemorrhage
Advertisements

Acute Surgical Conditions & Trauma Management :
Management of a Pt with Hematemesis
Lower GI Bleeding.
LOWER GI BLEEDS Jeeves. Definition  The loss of blood from the GI tract distal to the ligament of Trietz.  This is the anatomical marker for the junction.
Dr Shi Hong Shen. 1. Diverticular disease 2. Angiodysplasia 3. Polyps 4. Carcinoma 5. Inflammatory Bowel Disease 6. Haemorrhoids 7. Mesenteric thrombosis.
Gastrointestinal Haemorrhage
Gastrointestinal Haemorrhage
COLORECTAL BLEEDING: A MULTIDISCIPLINARY APPROACH PATIENTS EVALUATION AND DIAGNOSIS: COLONSCOPY Stefania Caronna MD Dept. of Gastroenterology Molinette.
PR BLEEDING BY HELEN BERMINGHAM. MESENTERIC BLOOD VESSELS Coeliac trunk T12 foregut left gastric common heptic splenic SMA L1 midgut inferiorpancreaticoduodenal.
Case 1 21 year old male office worker GP referral, “IBS not responding to Rx 3 month history of abdominal discomfort, worse after eating, can keep him.
Acute Upper Gastrointestinal Hemorrhage “Surgical Perspective”
Lower Gastrointestinal Bleeding
LOWER GASTROINTESTIRAL BLEEDING Asoc. Prof. Dr.Orhan Yalçın Ministry of Health, Okmeydanı Education and Research Hospital, Turkey.
Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D.
DYSPEPSIA Dr.Vishal Rathore. Dyspepsia popularly known as indigestion meaning hard or difficult digestion, is a medical condition characterized by chronic.
Peptic ulcer disease Hannah Vawda FY1.
Peptic Ulcer Disease Biol E /11/06. From: Current Diagnosis & Treatment in Gastroenterology - 2nd Ed. (2003)
Upper GI Bleeding Tad Kim, M.D. UF Surgery (c) ; (p)
Chris Harmston Consultant Colorectal Surgeon UHCW
Upper GI Bleeding Tad Kim, M.D. Connie Lee, M.D..
Haematemesis Lent The case: Mr J O’F 48 year old jockey (divorced, no recent wins). Presents at 2am with a big haematemesis Unable to give a history.
Gastrointestinal Bleeding PCOM Internal Medicine Residents 2004.
Gastrointestinal Bleeding G Muthukumarasamy Specialist Registrar in General Surgery.
GASTROINTESTINAL (G.I) BLEEDING
Core Topic UCI Internal Medicine Residency Learning Objectives Review the major causes of upper GI bleeding and important elements of the history.
Bowel Cancer Alex Hill. Why screen for bowel cancer?  Bowel cancer causes deaths per yr  It may be detected at asymptomatic stage by simple, safe.
Gastro Intestinal Bleeding By: Abdulrahman Sindi ED Resident.
شاهین زارع.
Upper and Lower GI Investigation of Elderly Patients who are Iron Deficient American Journal of Medicine July 1999.
GASTROINTESTINAL BLEEDING
Bleeding from the Gut Clinical approach Severity Vital signs Haematocrit Beware ongoing losses Acute onset or chronic blood loss Fe deficiency Stigmata.
From Mouth to Rectum and Everywhere in Between
MAJOR LOWER GASTRO-INTESTINAL BLEEDING
Fariba Jafari. Definition Outpouchings of the colon Located at sites where blood vessels enter the colonic wall Inflamed as a result of obstruction by.
Iron deficiency anaemia Christian Selinger Consultant Gastroenterologist.
Lower GI Bleed T R Wilson Doncaster Royal Infirmary.
Adult Medical- Surgical Nursing
Clinical Case: Mr Veri Pushi: 45 year old married self-employed property developer You are present in casualty when this gentleman is brought in by ambulance.
Management of lower GI bleeding M K Alam MS; FRCS ALMAAREFA COLLEGE.
Gastrointestinal Haemorrhage Rebecca Shields Clinical Teaching Fellow UHCW.
Colonoscopy Not the cure for Acute Lower GI Bleeding
Upper Gastrointestinal Disease Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics.
Gastrointestinal Haemorrhage
PROF. IBRAHIM A. AL-MOFLEH Professor of Medicine, College of Medicine & University Hospitals, KSU PROF. IBRAHIM A. AL-MOFLEH Professor of Medicine, College.
ULCERATIVE COLITIS. Ulcerative colitis is an idiopathic chronic inflammatory disease of the colon that follows a course of relapse and remission. In a.
Diagnosis of Gastrointestinal Bleeding Liu Zhenhua.
Lec 10 Upper Gastrointestinal Bleeding Dr;Basim Rassam Al-Madena copy1.
Working Template Present case - Jay Clinical Approach (Hx, PE, definition of terms) Salient features/ Pivotal signs and symptoms Problems of the Patient.
Doreen Benary 3rd Year Medical Student NY Medical Programme, TAU Sheba MC, Internal Medicine 6 Head: Prof Avi Livne.
GI Bleeding Presentations Dr Mark Putland Co-DEMT Bendigo Health Care Group.
Upper Gastrointestinal Cancers Top ⑩ Tips
Approach to gastrointestinal bleeding
GASTRO INTESTINAL BLEED
GIT Bleeding.
Matt Warren. Gastroenterology North Tyneside Hospital
Acute Upper GIT bleeding
UPPER GI Bleed BY DR DENNIS PRABHU DAYAL.
PROF. IBRAHIM A. AL-MOFLEH
Upper Gastrointestinal Bleeding Dr;Basim Rassam
Acute upper gastrointestinal Bleeding
Management of lower GI bleeding
Qassim J. odda Master in adult nursing
Common cancers and NICE
Nelson Essential of pedaitrics
Gastrointestinal Haemorrhage
GASTROINESTINAL BLEEDING
Dilemma.
Colorectal Disease: Conditions and Treatment Updates
Presentation transcript:

Gastrointestinal Haemorrhage Joel Burton Clinical Teaching Fellow UHCW

Acute Block Objectives - Outline 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

Recognise a GI Bleed

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

GI bleeding  What colour can blood be?  Why does it change?  Always visible?

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

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

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)

Resuscitation  Assess for signs of hypovolaemic shock  A&B  Large clots can block airway  Risk of aspiration  O2 15l  Attach monitoring

Circulation - Interventions  2 large bore IV cannulae (14 or 16 G)  Send blood for FBC, clotting, G&S or crossmatch  Fluids or blood?  Urinary catheter?

Blood

Blood sampling  Group and save  This will not get you blood!  Crossmatch  This will actually get you blood!

Blood  O Negative  immediately  Type specific  20 mins  Fully X matched  40 mins plus  Consider massive haemorrhage alert protocol

Massive Haemorrhage Protocol  Blood loss  of 2000ml blood loss in 2 hours, or  Pulse >120/min, SBP 120/min, SBP <80mmHg, or  at rate of 150 mls/min, or  Massive trauma situations

Massive Haemorrhage Protocol  Emergency call via switchboard  At UHCW it gets you:  Staff  Pack 1  Pack 2

Massive Haemorrhage Protocol  Staff  Team leader (consultant in relevant specialty)  Runner (porter)  Communication lead  IV access and sample taker  Senior surgeon  Senior ITU & ODP  Receptionist (in ED)

Massive Haemorrhage Protocol  Pack one  4 units red cells  2 units FFP  Pack two  4 units red cells  4 units FFP  1 unit platelets

Medical Management  Stop  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  Emma Smith unstable in ED resus with a massive upper GI bleed  DOB 01/07/55  Hospital Number AA  5 Carrington Close  Coventry  Prescribe  3units red cells

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

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

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

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

Blatchford Score (pre endoscopy)  Predicts need for hospital based treatment  Score of 6 or more have 50% risk of requiring intervention  No subjective variables (e.g. severity of systemic diseases)  No need for OGD to complete the score.  Systolic BP  Pulse  Melena  Syncope  Coborbidity  Urea  Hb

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, >4u blood to keep BP >100  Continuing fresh melaena / haematemesis  Re-bleed / unstable post resuscitation  If fails, may need emergency surgery

Mallory Weiss tear

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

Minor Bleeds – Anorectal  Bright red blood on toilet paper, not mixed with stools  Diagnosed by typical PR appearances

Anal Fissure

Haemorrhoids

Fistula in ano

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

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

Blood tests  FBC  Hb level  ? Chronic microcytic anaemia  LFTs & Clotting  Clotting disorders and risk factors for these  Liver failure, and risk of varacies  Group and save

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

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 (Crohn’s)

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

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

Case Studies  Small groups, same colour cases  For each case, list and justify:  Diagnosis & 2 main differentials  Severity of Bleed  Blatchford or Rockall Score if appropriate  Investigations & Management

Red Case  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 to confirm diagnosis  Observe, Antibiotics if diverticulitis

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

Diverticular Disease  Hx  Prone to constipation  Loose motion, then blood mixed in, then only blood  Known history  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

Yellow Case  Diagnosis  Ischaemic colitis  Severity  Severe  Blatchford score  n/a  Ix and Mx  ABCDE resuscitation  ECG,  Bloods (Hb, U&Es, inflammatory markers),  CT abdomen with contrast  NBM, IVI, Antibiotics, +/- Surgery (or embolectomy by interventional radiology

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

Blue Case  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, with blood/FFP  IV antibiotics and vitamin K  Endoscopy for banding  Consider terlipressin

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

Rockall Score Score Variable0123 Age <60 years years >80 years Shock No shock TachycardiaHypotension 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 <2.5%) >=2 urgent OGD (Mortality 5%) Post OGD Score <3 good prognosis, early discharge >8 high risk of death

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

Green Case  Diagnosis  Duodenal Ulcer  Severity  Severe  Blachford score  10 (Systolic BP 3, pulse 1, melena 1, syncope 0, comorbidity 0, urea 2, Hb 3)  Ix and Mx  ABCDE, resuscitate with blood  IV Omeprazole, endoscopy within 24hrs and close monitoring

Green Case  OGD after 2hrs (pt deteriorated)  Blood in stomach ++  Large duodenal ulcer, spurting blood  What is the Rockall Score?

Rockall Score Score Variable0123 Age <60 years years >80 years Shock No shock TachycardiaHypotension 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 <2.5%) >=2 urgent OGD (Mortality 5%) Post OGD Score <3 good prognosis, early discharge >8 high risk of death

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

Case 2  Diagnosis  Lower GI bleed – ‘chronic’  Secondary to caecal carcinoma  Ix and Mx  Transfuse for Hb >7  CT scan  Colonoscopy  Definitive treatment for cancer (Right Hemicolectomy)

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

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)

Summary  Colour of blood important for location of bleed  Assess severity of bleed (including Blachford Score) to decide urgency of management  Simultaneous Resuscitation, investigations & management if unwell  Targeted investigations for less sick patients

ANY QUESTIONS?