Gastrointestinal Haemorrhage Rebecca Shields Clinical Teaching Fellow UHCW

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

Recognise a GI Bleed

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

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

Colours of Blood ColourVomitStool Bright Red √√ Dark Red x√ Greenxx Blackx√ Brown√ x ? No motion / vomit ??

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

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

Consider occult GI blood loss when:  Unexplained anaemia  Sudden hypotension and tachycardia, often fluid responsive  Shocked patient - PMH of GI bleeds or risk factors

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 X- match, inform blood bank  IV fluids to maintain BP>100 systolic  Start with up to 2l 0.9% Sodium Chloride STAT  Then progress to blood  IV FFP if variceal bleed suspected or INR>1.3  Urinary catheter

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Blood

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

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

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 A&E 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 and OP OGD  How can we predict mortality?

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

Rockall Score (post endoscopy) Score Variable0123 Age <60 years years >80 years Shock No shock TachycardiaHypotension 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

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  Haemorrhoids  Feel “lump”, Itch  Anal Fissure  Anal pain +++ with motions  Fistula in ano  Soiling on underwear, recurrent abscesses

Anal Fissure

Haemorrhoids

Fistula in ano

Moderate & Severe Bleeds  Resuscitation including Transfusion  Medical Management  Haemostasis  Treatment of underlying disease

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  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

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 Case 2, list and justify:  Diagnosis & 2 main differentials  Severity of Bleed  Blatchford or Rockall Score (pre endoscopy) if appropriate  Investigations & Management

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  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

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

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

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

Ischaemic Colitis  Hx  AF / IHD  Generalised pain  Colitic symptoms  Deteriorating rapidly  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, 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

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)

Case Blue 2  OGD Results:  Large oesophageal varices, no active bleeding.  Clots in stomach.  Varices banded.  What is the Rockall Score?

Rockall Score Score Post endoscopy? 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

Yellow sclera

Caput Medusae

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 epigastrum, no guarding, slightly distended, no organomegaly  PR – black, tarry motion, no red blood or faeces  Other examination normal

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

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

Rockall Score (Upper GI only) Score Post endoscopy 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

Gastric and Duodenal Ulcers

Gastritis

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

Other Bleeds Post op Complications  Very rare  Must be considered if recent intervention  More commonly, re- bleeds post haemostatic 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

Colon Cancer

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

Gastric Cancer

Oesophageal cancer

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 (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  Use guidelines / pathways to aid management  ASK FOR HELP when needed!!!

ANY QUESTIONS?