1. Gastrointestinal Haemorrhage
Phil Polson
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. Patient Pathway – “Normal”
Treatment
Presentation
History & Examination
Provisional Diagnosis
Investigations
Specific Diagnosis

4. Patient Pathway – “Acute”
Presentation
Unstable Patient
Specific Treatment
Stable Patient
Further Investigations
Confirm Diagnosis
Resuscitation
Haemostasis
Medical Management
Investigations
History & Examination
Working Diagnosis

5. Recognise a GI Bleed

6. Colours of Blood Colour Vomit Stool Bright Red √ Dark Red x Green
Black
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
COULD ALL BE 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. 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
Ask groups to call out most common upper GI bleed, then show list. Likewise with Lower GI causes. Don’t let it drag

11. Causes - Upper GI (80%) Peptic ulcer disease – 50%
Erosive Gastritis / Oesophagitis – 18%
Varices – 10%
Mallory Weiss tear – 10%
Cancer – Oesophageal or Gastric – 6%
Other, including Dieulafoy’s lesion – 6%
Mallory Weiss is a laceration at the junction of the oesophagus and stomach, due to forceful coughing or vomiting.

12. Causes - Lower GI (20%) Diverticular disease - 60%
Colitis (IBD & ischaemic) – 13%
Benign anorectal (haemorrhoids, fissures, fistulas) – 11%
Malignancy – 9%
Coagulopathy – 4%
Angiodysplasia – 3%
Post surgical / polypectomy
Angiodysplasia – vascular malformation, often small but multiple, causing subtle symptoms. Ischaemic colitis – usually elderly people, cause for ischaemia generally unknown but can be embolic.

13. General Management Urgency of Management Resuscitation
Medical Management
Haemostasis
Treatment of underlying disease

14. Urgency of Management Severe bleeds Moderate 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

15. 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)

16. Low risk patients Consider for discharge with outpatient follow-up if:
Age <60, and;
No evidence of haemodynamic disturbance (SBP > 100mmHg, pulse < 100bpm), and;
Not a current inpatient or transfer, and;
No witnessed haematemesis or haematochezia (upper GI bleed) or
No evidence of gross rectal bleeding, and an obvious anorectal source of bleeding on rectal examination +/- rigid sigmoidoscopy (lower GI bleed)

17. 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

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

19. Rockall Score (Upper GI only)
Variable 1 2 3
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
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
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 19

20. 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

21. Mallory Weiss tear

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

23. 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

24. Anal Fissure

25. Haemorrhoids

26. Fistula in ano

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

28. Resuscitation A B C D E

29. Airway & Breathing Large clots can block airway
Reduced conscious level (shock/encephalopathy)
Risk of aspiration
Give 15l/min oxygen via face mask 29

30. Circulation – recognising shocked patients
Pale
Clammy skin
High Cap Refill (>2s)
Weak pulse
Tachycardia (NB beta blockers)
Hypotension
(High resp rate)
(Confusion)

31. 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
Cross match at least six units for bleeding varices. 31

32. Blood

33. Blood O Negative Type specific (red label ...) Fully X matched
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

34. Massive Haemorrhage Protocol
Blood loss
of 1 blood volume (5l) within 24hrs or
of 50% blood volume (2.5l) within 3hrs
at rate of 150 mls/min

35. Medical Management Stop Give Consider 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

36. 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

37. Investigations - Types
Bedside
Blood tests
Imaging
Endoscopy
Surgery
Further details of all of these on handout
Make 4 posters, bedside, blood tests, imaging, endoscopy & surgery 37

38. Case Studies Small groups, same colour cases
For Case 2, list and justify:
Diagnosis & 2 main differentials
Severity of Bleed
Rockall Score (pre endoscopy) if appropriate
Investigations & Management

39. 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

40. Case Red 2 Diagnosis Severity Rockall Score Ix and Mx
Diverticular bleed
Severity
Moderate
Rockall 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

41. 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

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

43. Diverticular Disease
Main lumen and false lumen 43

44. Diverticular Disease Hx Ex 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

45. Inflammatory Bowel DiseaseHx
Known IBD
Loose motions, up to 20x/day
Now mucus and blood, increased frequency Ex
Thin
Tender abdomen
Systemic signs of IBD

46. Ulcerative Colitis

47. Crohn’s Disease

48. 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

49. Case Yellow 2 Diagnosis Severity Rockall Score Ix and Mx
Ischaemic colitis
Severity
Severe
Rockall 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

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

51. 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
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

52. Case Blue 2 Diagnosis Severity Rockall Score Ix and Mx
Bleeding varices
Severity
Severe
Rockall Score
Age 0, Shock 2, Co-morbidity 3 = Total 5
Ix and Mx
ABCDE resuscitation, inc up to 2l fluids, FFP, ? blood
Terlipressin, Tazocin, ?Vitamin K, Urgent senior r/v, urgent endoscopy

53. Rockall Score (Upper GI only)
Pre endoscopy 5
Variable 1 2 3
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
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
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 53

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

55. Rockall Score (Upper GI only)
Post endoscopy?
Variable 1 2 3
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
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
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

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

57. Yellow sclera

58. Caput Medusae

59. Gynaecomastia

60. Palmar erythema

61. Dupuytren’s contracture

62. 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

63. Case Green 2 Diagnosis Severity Rockall Score Ix and Mx Duodenal Ulcer
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

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

65. Rockall Score (Upper GI only)
Post endoscopy score?
Variable 1 2 3
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
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
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 65

66. Gastric and Duodenal Ulcers

67. Gastritis
Same causes as ulcer. Diffuse. Oozes blood rather than catastrophic haemorrage. 67

68. Peptic ulcers and ErosionsHx
Associated with typical pain
NSAID use
Previous gastritis / ulcers
Stress (including operations) Ex
Epigastric tenderness / guarding

69. 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

70. Other Bleeds Post op Complications Dieulafoy’s lesion Very rare
Must be considered if recent intervention
More commonly, re-bleeds post haemostatic interventions
Can be very large bleeds, clots+++
AV malformation
Very difficult to see at endoscopy
Frequently re-bleeds after intervention
Can be missed, so can bleed after “negative” endoscopy

71. Case 3
PC/HPC 48F, 1/12 increasing “heartburn”, associated with weight loss (2/12), loss of appetite (2-3/52), and being “off colour”. Bowels unchanged
Hb 6.0 MCV 74 (normal ) at GP today, causing admission (last Hb 1 ½ yrs ago 12.5)
PMH –normal OGD 2/52 ago, to Ix indigestion ?awaiting further tests
Normally fit and well
O/E – Pale, thin. Pulse 90, BP 140/85 (no postural drop)
Abdomen - Vague mass RIF, non tender
PR – soft brown stool.

72. Case 3 Diagnosis Ix and Mx Lower GI bleed – ‘chronic’
Secondary to caecal carcinoma
Ix and Mx
Slow transfusion, +/- diuretic
CT scan
Colonoscopy
Definitive treatment for cancer (Right Hemicolectomy)

73. Colon Cancer

74. Colorectal MalignancyHx
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

75. Gastric Cancer
Gastric malignancy. What makes it look malignant? 75

76. Oesophageal cancer
Craggy, irregular appearance on one side, smooth on the other. 76

77. Oesophageal & Gastric MalignanciesHx
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)

78. 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

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

80. Any Questions?

81. Appendix – Investigations for GI bleed patients

82. Bedside Faecal Occult Blood (FOB) Proctoscopy Rigid Sigmoidoscopy
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

83. Blood tests FBC LFTs & Clotting Tumour Markers G&S / Crossmatch
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

84. 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

85. CT Angiogram
Figure 1c.  Active sigmoid bleeding in a 94-year-old woman who presented with bright red blood from the rectum. (a, b) Axial (a) and coronal (b) CT angiograms demonstrate active contrast material extravasation into the sigmoid colon (arrow). Note the multiple colonic diverticuli in this region and the contrast material–filled diverticulum that is optimally demonstrated on the coronal image, presumably representing the site of hemorrhage. (c) Findings on an IMA angiogram confirm the presence of active sigmoid bleeding (arrowheads). The patient was treated successfully with coil embolization.
Laing C J et al. Radiographics 2007;27:
©2007 by Radiological Society of North America

86. 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)

87. Transverse CT image
56-year-old man with pseudomembranous colitis who was undergoing antibiotic treatment for endocarditis. In the sigmoid colon, a shaggy thickened bowel wall with alternating areas of necrosis (arrows) and plaques is visible

88. 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

89. 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