1. Gastrointestinal Haemorrhage Joel Burton Clinical Teaching Fellow UHCW

2. 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

3. Recognise a GI Bleed

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

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

6. 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

8. 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

9. 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)

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

11. 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?

12. Blood

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

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

15. 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

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

17. 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)

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

19. 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

20. Prescribing exercise  Emma Smith unstable in ED resus with a massive upper GI bleed  DOB 01/07/55  Hospital Number AA111000  5 Carrington Close  Coventry  Prescribe  3units red cells

21. 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

22. 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

23. 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

24. 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

25. Case 1  Diagnosis  Mallory Weiss tear  Severity  Mild  Ix and Mx  Senior r/v with view to discharge  How can we predict mortality?

26. 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

27. 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

28. Mallory Weiss tear

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

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

31. Anal Fissure

32. Haemorrhoids

33. Fistula in ano

34. 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

35. 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

36. 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

37. 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

38. 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)

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

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

48. 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

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

50. Rockall Score Score Variable0123 Age <60 years 60-79 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

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

52. 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

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

54. Rockall Score Score Variable0123 Age <60 years 60-79 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

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

56. 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

57. 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)

58. 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

59. 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)

60. 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

61. ANY QUESTIONS?