1. Mohammad Mobasheri SpR General Surgery
GI Bleed
Mohammad Mobasheri
SpR General Surgery

2. GI Bleeding Maybe classified into:
Upper GI bleeding (proximal to DJ flexure)
Variceal bleeding
Non-variceal bleeding
Lower GI bleeding (distal to DJ flexure)
Upper GI bleeding 4x more common than lower GI bleeding
Emergency resuscitation same for upper and lower GI bleeds

3. Emegency Resuscitation
Takes priority over determining the diagnosis/cause
ABC (main focus is ‘C’)
Oxygen: 15L Non-rebreath mask
2 large bore cannulae into both ante-cubital fossae
Take bloods at same time for FBC, U&E, LFT, Clotting, X match 6Units
Catheterise
IVF initially then blood as soon as available (depending on urgency: O-, Group specific, fully X-matched)
Monitor response to resuscitation frequently (HR, BP, urine output, level of consciousness, peripheral temperature, CRT)
Stop anti-coagulants and correct any clotting derrangement
NG tube and aspiration (will help differentiate upper from lower GI bleed)
Organise definitive treatment (endoscopic/radiological/surgical)

4. Estimating Degree of Blood Loss
RR, HR, and BP can be used to estimate degree of blood loss/hypovolaemia
Class I
Class II
Class III
Class IV
Volume Loss (ml)
0-750
>2000
Loss (%)
0-15
15-30
30-40
>40 RR
14-20
20-30 HR
<100
>100
>120
>140 BP
Unchanged
Reduced
Urine Output (ml/hr)
>30
5-15
Anuric
Mental State
Restless
Anxious
Anxious/confused
Confused/ lethargic

5. History and Examination
Aim of history and examination is 3 fold
1. Identify likely source – upper vs lower – and potential cause
2. Determine severity of bleeding
3. Identify precipitants (e.g. Drugs)

6. History in patients with GI bleeding
PC/HPC
Duration, frequency, and volume of bleeding (indicate severity of bleeding)
Nature of bleeding: will point to source
Haematemesis (fresh or coffee ground)/melaena suggest upper GI bleed. (Note a very brisk upper GI bleed can present with dark or bright red blood PR).
PR Dark red blood suggests colon
PR Bright red blood suggests rectum, anus
If PR bleeding, is blood being passed alone or with bowel opening (if alone suggests heavier bleeding)
If with bowel opening is blood mixed with the stool (colonic), coating the stool (colonic/rectal), in the toilet water (anal), on wiping (anal)
Ask about associated upper or lower GI symptoms that may point to underlying cause
E.g. Upper abdominal pain/dyspeptic symptoms suggest upper GI cause such as peptic ulcer
E.g. 2. lower abdo pain, bowel symptoms such as diarrhoea or a background of change in bowel habit suggest lower GI cause e.g. Colitis, cancer
Previous episodes of bleeding and cause
PMH
History of any diseases that can result in GI bleeding, e.g. Peptic ulcer disease, diverticular disease, liver disease/cirrhosis
Bleeding disorders e.g. haemophilia DH
Anti-platelets or anti-coagulants can exacerbate bleeding
NSAIDs and steroids may point to PUD SH
Alcoholics at risk of liver disease and possible variceal bleeding as a result
Smokers at risk of peptic ulcer disease

7. Examination in patients with GI bleeding
Reduced level of consiousness
Pale and clammy
Cool peripheries
Reduced CRT
Tachcardic and thready pulse
Hypotensive with narrow pulse pressure
Tenderness on abdominal examination may point to underlying cause e.g. Epigastric  peptic ulcer
Stigmata of chronic liver disease (palmer erythema, leukonychia, dupuytrens contracture, liver flap, jaundice, spider naevi, gynacomastia, shifting dullness/ascites)
Digital rectal examination may reveal melaena, dark red blood, bright red blood

8. Upper GI bleed

9. Upper GI bleed
Upper GI bleeding refers to bleeding from oesophagus, stomach, duodenum (i.e. Proximal to ligmanet of treitz)
Bleeding from jejunum/ileum is not common

10. Presentation Acute Upper GI bleeding presents as:
Haematemesis (vomiting of fresh blood)
Coffee ground vomit (partially digested blood)
Melaena (black tarry stools PR)
If bleeding very brisk and severe then can present with red blood PR!
If bleeding very slow and occult then can present with iron deficiency anaemia

11. Causes Cause of Bleeding Relative Frequency Peptic Ulcer 44
Oesophagitis 28
Gastritis/erosions 26
Duodenitis 15
Varices 13
Portal hypertensive gastropathy 7
Malignancy 5
Mallory Weiss tear
Vascular Malformation 3
Other (e.g. Aortoenteric fistula)
rare

12. Risk Stratification: Rockall Score
Identifies patients at risk of adverse outcome following acute upper GI bleed
Score <3 carries good prognosis
Score >8 carries high risk of mortality
Variable
Score 0
Score 1
Score 2
Score 3
Age
<60
60-79
>80 -
Shock
Nil
HR >100
SBP <100
Co-morbidity
Nil major
IHD/CCF/major morbidity
Renal failure/liver failure
Diagnosis
Mallory Weiss tear
All other diagnoses
GI malignancy
Endoscopic Findings
None
Blood, adherent clot, spurting vessel

13. Management (Non-variceal)
Emergency resuscitation as already described
Endoscopy
Urgent OGD (within 24hrs) – diagnostic and therepeutic
Treatment administered if active bleeding, visible vessel, adherent blood clot
Treatment options include injection (adrenaline), coagulation, clipping
If re-bleeds then arrange urgent repeat OGD
Pharmacology
PPI (infusion) – pH >6 stabilises clots and reduces risk of re-bleeding following endoscopic haemostasis
Tranexamic acid (anti-fibrinolytic) – maybe of benefit (more studies needed)
If H pylori positive then for eradication therapy
Stop NSAIDs/aspirin/clopidogrel/warfarin/steroids if safe to do so (risk:benefit analysis)

14. Management (Non-variceal)
Surgery
Reserved for patients with failed medical management (ongoing bleeding despite 2x OGD)
Nature of operation depends on cause of bleeding (most commonly performed in context of bleeding peptic ulcer: DU>GU)
E.g. Under-running of ulcer (bleeding DU), wedge excision of bleeding lesion (e.g. GU), partial/total gastrectomy (malignancy)

15. Variceal Bleeds
Suspect if upper GI bleed in patient with history of chronic liver disease/cirrhosis or stigmata on clinical examination
Liver Cirrhosis results in portal hypertension and development of porto-systemic anastamosis (opening or dilatation of pre-existing vascular channels connecting portal and systemic circulations)
Sites of porto-systemic anastamosis include:
Oesophagus (P= eosophageal branch of L gastric v, S= oesophageal branch of azygous v)
Umbilicus (P= para-umbilical v, S= infeior epigastric v)
Retroperitoneal (P= right/middle/left colic v, S= renal/supra-renal/gonadal v)
Rectal (P= superior rectal v, S= middle/inferior rectal v)
Furthermore, clotting derrangement in those with chronic liver disease can worsen bleeding

16. Management of Variceal bleeds
Emergency resuscitation as already described
Drugs
Somatostatin/octreotide – vasoconstricts splanchnic circulation and reduces pressure in portal system
Terlipressin – vasoconstricts splanchnic circulation and reduces pressure in portal system
Propanolol – used only in context of primary prevention (in those found to have varices to reduce risk of first bleed)
Endoscopy
Band ligation
Injection sclerotherapy
Balloon tamponade – sengstaken-blakemore tube
Rarely used now and usually only as temporary measure if failed endoscopic management
Radiological procedure – used if failed medical/endoscopic Mx
Selective catheterisation and embolisation of vessels feeding the varices
TIPSS procedure: transjugular intrahepatic porto-systemic shunt
shunt between hepatic vein and portal vein branch to reduce portal pressure and bleeding from varices): performed if failed medical and endoscopic management
Can worsen hepatic encephalopathy
Surgical
Surgical porto-systemic shunts (often spleno-renal)
Liver transplantation (patients often given TIPP/surgical shunt whilst awaiting this)

17. TIPSS
Sengstaken-Blakemore Tube

18. Surgical porto-systemic shunt (spleno-renal shunt)

19. Variceal Bleed: Prognosis
Prognosis closely related to severity of underlying chronic liver disease (Childs-Pugh grading)
Child-Pugh classification grades severity of liver disease into A,B,C based on degree of ascites, encephalopathy, bilirubin, albumin, INR
Mortality 32% Childs A, 46% Childs B, 79% Childs C

20. Lower GI Bleed

21. Lower GI bleeding
Lower GI bleed refers to bleeding arising distal to the ligament of Treitz (DJ flexure)
Although this includes jejunum and ileum bleeding from these sites is rare (<5%)
Vast majority of lower GI bleeding arises from colon/rectum/anus

22. Presentation Lower GI bleeding presents as:
Dark red blood PR – more proximal bleeding point (e.g. Distal small bowel, colon)
Bright red blood PR – more distal bleeding point (e.g. rectum, anus)
PR blood maybe:
mixed or separate from the stool
If separate from the stool it maybe noticed in the toilet water or on wiping
Passed with motion or alone
If blood mixed with stool (as oppose to separate from it) suggests more proximal bleeding
If bleeding very slow and occult then can present with iron deficiency anaemia

23. Causes Colon Rectum Anus Diverticular Disease Polyps Haemorrhoids
Malignancy
Fissure
Proctitis
Colitis
Angiodysplasia

24. Management Emergency resuscitation as already described
Pharmacological
Stop NSAIDS/anti-platelets/anti-coagulants if safe
Tranexamic acid
Endoscopic
OGD (15% of patients with severe acute PR bleeding will have an upper GI source!)
Colonoscopy – diagnostic and therepeutic (injection, diathermy, clipping)

25. Management Radiological CT angiogram – diagnostic only (non-invasive)
Determines site and cause of bleeding
Mesenteric Angiogram – diagnostic and therepeutic (but invasive)
Determines site of bleeding and allows embolisation of bleeding vessel
Can result in colonic ischaemia
Nuclear Scintigraphy – technetium labelled red blood cells: diagnostic only
Determines site of bleeding only (not cause)

26. Management
Surgical – Last resort in management as very difficult to determine bleeding point at laparotomy
Segmental colectomy – where site of bleeding is known
Subtotal colectomy – where site of bleeding unclear
Beware of small bowel bleeding – always embarassing when bleeding continues after large bowel removed!

27. Management Flow Chart for Severe lower GI bleeding
Resuscitate
OGD (to exclude upper GI cause for severe PR bleeding)
Colonoscopy (to identify site and cause of bleeding and to treat bleeding by injection/diathermy/clipping) – often unsuccesful as blood obscures views
CT angiogram (to identify site and cause of bleeding)
Mesenteric angiogram (to identify site of bleeding and treat bleeding by embolisation of vessel)
Surgery

28. Management
As 85% of lower GI bleeds will settle spontaneously the interventions mentioned on previous slide are reserved for:
Severe/Life threatening bleeds
In the 85% where bleeding settles spontaneously OPD investigation is required to determine underlying cause:
Endoscopy: flexible sigmoidoscopy, colonoscopy
Barium enema

29. Iron Deficiency Anaemia

30. Definition Insufficient iron in the body for haemopoeisis
Decrease Hb and MCV
Decreased serum iron and Ferritin
Increased TIBC and serum transferrin

31. Causes Increased Iron demand Insufficient Iron intake
Chronic Blood loss
Think Chronic bleeding (often occult) from GI tract in men and post-menopausal females (pre-menopause menorrhagia most common cause) e.g. Colonic polyp or cancer, gastric/duodenal ulcer or malignancy
Chronic haemolysis
Pregnancy
Insufficient Iron intake
Diet lacking in iron
Vegans – plant based iron poorly absorbed compared to meat based iron
Malabsorption of iron
Small intestinal disease e.g. Crohn’s, caeliac disease
Lack of vitamin C (important for iron absorption)

32. Causes
In adults >50yrs of age the most common cause of Iron deficiency anaemia is chronic occult GI bleeding
In females <50yrs most common cause is blood loss during menses with inadequate replacement
In developing world intestinal parasitic infection causing chronic blood loss from the GI tract is the most common cause of iron deficiency anaemia (rare in developed world)

33. Investigations To confirm iron deficiency anaemia OGD and colonoscopy
Hb, MCV, Ferritin, transferrin, TIBC
Rarely bone marrow aspirate (gold standard but invasive: rarely performed)
OGD and colonoscopy
Perform in males and post-menopausal females
In pre-menopausal females menorrhagia is most common cause and often OGD/colonoscopy not required unless other symptoms warrant it (e.g. dyspepsia, dysphagia, PR bleeding, change in bowel habit, family history etc.)
Note that iron deficiency anaemia maybe the only sign of an occult GI malignancy

34. The End
Questions