gastrointestinal haemorrhage mrs esther mitchell clinical teaching fellow

Gastrointestinal Haemorrhage

Mrs Esther Mitchell

Clinical Teaching Fellow

Acute Block Objectives

GI Bleeds Assess the likely causes of upper GI bleeds from

history and examination Initiate 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 ill patient Resuscitation

Today’s Objectives Knowledge

Know what colours are likely to represent blood in a vomit or stool sample

Understand why blood changes colour in the GI tract List common causes of lower GI bleeds Know symptom complexes that clinically differentiate these

causes Know the initial management of upper GI bleed patients List features on history and examination that suggest Varaceel

bleeds List 5 other causes of upper GI bleed Describe the distinguishing features of these other presentations

Today’s Objectives continued Knowledge continued

Understand resuscitation of bleeding patient, including use of fluids and blood

Think about different types of investigations and what information can be obtained from them

Skills Fill in an upper GI bleed care pathway Be able to calculate a Rockal score Prescribe blood and IV drugs correctly

Attitudes Appreciate knowing purpose of investigations allows correct

choice of investigation Be aware of how serious upper GI bleeds can be Give GI bleed patients appropriate priority

Outline

Patient Pathways General principles & Worked Examples

Recognising a GI Bleed Causes of GI Bleeds Management Investigations

Including Case Study Group work sessions

Patient Pathway – “Normal”

Treatment

Presentation

History & Examination

Provisional Diagnosis

Investigations

Specific Diagnosis

Patient Pathway – “Acute”Presentation

Unstable Patient

Specific Treatment

Stable Patient

Further Investigations

Confirm Diagnosis

Resuscitation

HaemostasisHaemostasis

Medical Management

Medical Management

InvestigationsInvestigations



Working DiagnosisWorking

Diagnosis

Recognise a GI Bleed

What’s blood?

What colours can blood be? Why does it change colour in the GI tract? Do you always see blood if there’s GI

bleeding?

Colours of Blood

Colour Vomit Stool

Bright Red √ √

Dark Red x √

Green x x

Black x √

Brown √ x ?

No motion / vomit ? ?

Why does blood change colour?

Stomach – Acid Bright Red -> brown / coffee grounds

Small Bowel – Digestive enzymes Bright Red -> Dark Red

Colon – Bacteria Bright Red-> Dark Red -> Black

PR Bleeds (haematochezia)

Black – Cecum or Upper GI Melaena, Tar like, smelly

Dark Red – Transverse colon, Cecum Or Upper GI, large volume Loose / soft stools mixed with stools

Bright Red – Anus, Rectum, Sigmoid Mixed with stools - sigmoid / descending Coating stools / on paper – rectal / anal Rarely massive upper GI bleed

Consider occult GI blood loss when:

Unexplained anaemia Low volume chronic bleeds, eg Gastric Ca,

Cecal Ca Sudden episode of hypotension and

tachycardia, easily corrected Acute upper GI bleed melaena follows hours later

History of bleeds / risk factors, shocked pt Symptoms missed, or appear later

Causes of GI Bleed

Brainstorm all causes of GI bleeds Groups, 2-4 people 2 minutes

Make 2 lists, most common to least common Divide into upper & lower GI causes 1minute

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%

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

Management

Urgency of Management

Resuscitation including Transfusion Medical Management Haemostasis Treatment of underlying disease

Urgency of Management

Severe bleeds Resuscitation IP investigation +/- treatment

Moderate bleeds IP observation till 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)

Low risk patients

Consider for discharge or non-admission 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)

Introduction to Upper GI Bleed Pathway

3 minutes, working individually Fill in pathway for Case 1 Need:

coloured case study sheet (any colour) Upper GI bleed pathway

Use your imagination to fill in details not stated!!!

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

Rockall Score Age 0, Shock 0, co-morbidity 0 = 0

Ix and Mx Senior r/v with view to discharge and OP OGD

Rockall Score (Upper GI only)Score

Variable 0 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

(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

Endoscopy – Upper GI Bleeds

Severe bleeds Urgent OGD, inform Surgeons and Critical Care

Suspected Varceal bleed Continued bleeding, >4u blood to keep BP >100 Continuing fresh melaena / haematemesis Re-bleed / unstable post resuscitation

If fails, may need emergency surgery Moderate bleeds

IP OGD within 24hrs Minor bleeds / unproven

Consider OP OGD

Mallory Weiss tear

Mallory Weiss tear

Hx Vomiting (++) prior to haematemesis Often associated with alcohol Small volume blood “streaks”, mixed with vomit

Ex Normal examination

Benign 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 aino

Soiling on underwear, recurrent abscesses

Anal Fissure

Haemorrhoids

Fistula in aino

Moderate & Sever Bleeds

Resuscitation

Airway Breathing Circulation Disability Exposure

Airway & Breathing

Large clots can block the airway May have reduced conscious level

(shock/encephalopathy) At risk of aspiration due to vomiting Give 15l/min oxygen via face mask

Circulation – recognising shocked patients

Pale Clammy skin High Cap Refill (>2s) Weak pulse Tachycardia (NB beta blockers) Hypotention (High resp rate) (Confusion)

Circulation - Interventions 2 large bore IV cannulae (14 or 16 G) Send blood for FBC, clotting, G&S or X-match, if

bleeding is severe inform blood bank (see also massive haemorrage protocol)

IV fluids to maintain BP>100 systolic Start with up to 2l N Saline Stat Then progress to blood

IV FFP if variceal bleed suspected or INR>1.3 Urinary catheter

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

Purpose: to improve and streamline blood administration to those

with massive blood loss

Massive Hemorrhage protocol kicks in in the following circumstances: 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

Jo Blogs (dob 01/01/1955, hospital no X111000) is in Resus unstable with a massive upper GI bleed (probably variceal)

Please prescribe him: 2 units of blood IV Tazocin IV Terlipressin

Hand in your prescriptions at the coffee break (with your name on) to be checked

Questions & Coffee Break

Why do we do investigations in patients with GI bleeds?

Take a minute to brainstorm for reasons for investigating patients with GI bleeds

Investigations - Reasons

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

Investigations - Types

Bedside Blood tests Imaging Endoscopy Surgery

Further details of all of these in Appendix at end

Case Studies – Group Work

Groups of 4-5, same colour cases For Case 2, list and justify:

Diagnosis & 3 main differentials Severity of Bleed Rockall Score (pre endoscopy) if appropriate Investigations & Management

Make flip chart Present case afterwards Clinical Guidelines available if desired 5-10 minutes

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 (neither mild nor severe) 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

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

Eg definitive treatment of Cancers Ulcers Diverticular disease .....

Conservative, Medical or Surgical Urgent or Elective

Diverticular Disease

Diverticular Disease

Hx Prone to constipation Loose motion, then blood mixed in, then only

blood Often out of the blue Known diverticular disease

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

Ischemic colitis Severity

Severe Rockall Score

n/a Ix and Mx

ABCDE resuscitation ECG, Rigid sigi, Bloods (Hb, Trop I, U&Es,

inflammatory markers), CT abdo, Colonoscopy NBM, IVI, Antibiotics, +/- Surgery

Ischemic Colitis

Hx AF / IHD Generalised pain Colitic symptoms Very unwell

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 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 Varacies

Severity Severe

Rockall Score Age 0, Shock 2, Co-morbidity 3 = Total 5

Ix and Mx ABCDE resucitation, inc up to 2l fluids, FFP, ? blood Terlipressin, Tazocin, ?Vitamin K, Urgent senior r/v,

urgent endoscopy


Pre endoscopy 5

Variable 0 1 2 3






Diagnosis

(Post OGD)


All other diagnoses



(Post OGD)





Case Blue 2

OGD Results Large oesophageal varices, no active bleeding.

Clots in stomach. Varices banded. Post endoscopy Rockall Score

Diagnosis 1, SRH 2 Total 8 Outcome

High risk of death, needs close monitoring (e.g. HDU / ITU)


Post endoscopy 8

Variable 0 1 2 3






Diagnosis

(Post OGD)


All other diagnoses



(Post OGD)





Oesophagael Varices

Varices

Hx Known liver disease Known varices High alcohol intake

Ex Stigmata of liver disease Smell of alcohol on breath

Yellow sclera

Caput Medusae

Man with 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 epigastrium, no guarding, stomach slightly bloated, no

organomegaly PR – black, tarry motion, no red blood 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 (exclude perf)

Case Green 2

Results OGD after 2hrs (pt deteriorated) – Blood in

stomach ++, large duodenal ulcer, spurting blood Post endoscopy Rockall Score

Diagnosis 1, SRH 2, Total 5


Post endoscopy score 5

Variable 0 1 2 3






Diagnosis

(Post OGD)


All other diagnoses



(Post OGD)





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

Post op Complications

Rare ++++++ Must be considered if recent intervention More commonly, re-bleeds post haemostaic

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

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 80-100) 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)

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 80-100) 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) ECG immediately after arrival - ST depression Abdomen - Vague Mass RIF, non tender PR – soft brown stool on examining finger.

Case 3 Diagnosis

Angina caused by anaemia, secondary to cecal carcinoma

Severity Bleed is not acute but chronic, so n/a

Ix and Mx Treat angina (GTN spray), consider ACS Slow transfusion, +/- diuretic, as at risk of overload

(not acute blood loss, plus cardiac symptoms) CT scan +/- colonoscopy to confirm diagnosis Definitive treatment for cancer (Right Hemicolectomy)

Colon Cancer

Colorectal Malignancy

Hx Weigh loss, loss of appetite, lethargy Right sided – often only iron deficiency anaemia Left side – change in bowel habit, blood mixed with

stool, mucus Ex

Palpable mass (abdominal / PR) Visible weight loss Craggy liver edge May be normal

Gastric Cancer

Oesophageal cancer

Features of Upper GI cancers

1 minute, work in pairs Discuss features of history and examination

that suggest upper GI malignancy as cause for bleed

List 3 features on history 3 findings on examination

Oesophageal & Gastric Malignancies

Hx Weight loss, loss of appetite, general lethargy Dysphagia Known malignancy Recent stent insertion

Ex Emaciated Palpable craggy liver edge Palpable neck LN (rare) Visible mets (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 Working diagnosis to guide management Use guidelines / pathways to aid

management ASK FOR HELP when needed!!!

ANY QUESTIONS?

Appendix – Investigations for GI bleed patients

Bedside

Fecal Ocult 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 (Chron’s)

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

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

Flexi Sig and Colon – not in bleeding patients Poor vision – risk of perforation

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

gastrointestinal haemorrhage mrs esther mitchell clinical teaching fellow

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