1. Gastrointestinal Haemorrhage Rebecca Shields Clinical Teaching Fellow UHCW

2. 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

3. Recognise a GI Bleed

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

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

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

7. 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

8. 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

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

10. 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

11. 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)

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

13. 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

14. DDEEDDEE

15. Blood

16. 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

17. 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

18. 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

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

20. 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

21. 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

22. 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

23. 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

24. 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?

25. 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

26. Rockall Score (post endoscopy) Score Variable0123 Age <60 years 60-79 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

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

31. Anal Fissure

32. Haemorrhoids

33. Fistula in ano

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

35. 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

36. 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

37. 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

38. 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

39. 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)

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. Treatment of underlying disease  Definitive treatment of  Cancers  Ulcers  Diverticular disease  Conservative, Medical or Surgical  Urgent or Elective

47. Diverticular Disease

48.  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

49. 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

50. Ulcerative Colitis

51. Crohn’s Disease

52. 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

53. 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

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

55. 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

56. 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)

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

58. Rockall Score Score Post endoscopy? 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

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

60. Yellow sclera

61. Caput Medusae

62. Gynaecomastia

63. Palmar erythema

64. Dupuytren’s contracture

65. 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

66. 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

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

68. Rockall Score (Upper GI only) Score Post endoscopy 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

69. Gastric and Duodenal Ulcers

70. Gastritis

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

72. 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

73. 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

74. Colon Cancer

75. 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

76. Gastric Cancer

77. Oesophageal cancer

78. 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)

79. 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

80. Summary (2)  Likely diagnosis from history and examination  Use guidelines / pathways to aid management  ASK FOR HELP when needed!!!

81. ANY QUESTIONS?