gastrointestinal haemorrhage rebecca shields clinical teaching fellow uhcw

Gastrointestinal Gastrointestinal HaemorrhageHaemorrhage

Rebecca ShieldsRebecca Shields

Clinical Teaching FellowClinical Teaching Fellow

UHCWUHCW

Acute Block Objectives - OutlineAcute Block Objectives - Outline GI BleedsGI Bleeds

Explain the likely Explain the likely causes of upper GI bleedscauses of upper GI bleeds from from history and examination.history and examination.

Demonstrate an understanding of Demonstrate an understanding of initial initial managementmanagement of acute upper GI bleeds of acute upper GI bleeds

Distinguish common Distinguish common causes of lower GI bleedscauses of lower GI bleeds from history and examination.from history and examination.

Initiate appropriate Initiate appropriate investigationsinvestigations for lower GI for lower GI bleeds.bleeds.

Assessment of the acutely unwell patientAssessment of the acutely unwell patient ResuscitationResuscitation

Recognise a GI BleedRecognise a GI Bleed

HistoryHistory

AmountAmount DifficultDifficult Usually under estimatedUsually under estimated

Appearance Appearance What colours can blood be?What colours can blood be? Why does it change colour?Why does it change colour?

DurationDuration Associated SxAssociated Sx Risk factorsRisk factors

Blood loss exerciseBlood loss exercise

Estimate the volume of blood loss in each Estimate the volume of blood loss in each picturepicture

What colour can blood be?What colour can blood be? Why does it change?Why does it change? Always visible?Always visible?

Colours of BloodColours of BloodColourColour VomitVomit StoolStool

Bright RedBright Red √√ √√

Dark RedDark Red xx √√

GreenGreen xx xx

BlackBlack xx √√

BrownBrown √√ x ?x ?

No motion / vomitNo motion / vomit ?? ??

Why does blood change colour? Why does blood change colour? Stomach – AcidStomach – Acid

Bright Red Bright Red brown / coffee ground brown / coffee ground

Small Bowel – Digestive enzymesSmall Bowel – Digestive enzymes Bright Red Bright Red Dark Red Dark Red

Colon – BacteriaColon – Bacteria Bright Red Bright Red Dark Red Dark Red Black Black

PR Bleeds (haematochezia)PR Bleeds (haematochezia)

Upper GIUpper GI Black, Tar-like (Malaena)Black, Tar-like (Malaena)

Caecum / Transverse Caecum / Transverse coloncolon Dark Red, Loose stoolsDark Red, Loose stools Mixed with stoolsMixed with stools

Sigmoid / Anus / RectumSigmoid / Anus / Rectum Bright redBright red Mixed or separateMixed or separate

Massive upper GI bleedMassive upper GI bleed

Consider occult GI blood loss Consider occult GI blood loss when:when:

Unexplained anaemiaUnexplained anaemia

Sudden hypotension and tachycardia, Sudden hypotension and tachycardia, often fluid responsiveoften fluid responsive

Shocked patient - PMH of GI bleeds or Shocked patient - PMH of GI bleeds or risk factorsrisk factors

Urgency of ManagementUrgency of Management Severe bleedsSevere bleeds

ResuscitationResuscitation IP investigation +/- treatmentIP investigation +/- treatment

Moderate bleedsModerate bleeds IP observation until bleed stopsIP observation until bleed stops Often OP investigation +/- treatmentOften OP investigation +/- treatment

Mild / low risk bleedsMild / low risk bleeds Early dischargeEarly discharge OP investigation +/- treatmentOP investigation +/- treatment

Severe BleedsSevere Bleeds Severe / significant bleed if any of the Severe / significant bleed if any of the

following:following: Tachycardia >100Tachycardia >100 Systolic BP <100 (prior to fluid resuscitation)Systolic BP <100 (prior to fluid resuscitation) Postural hypotensionPostural hypotension Symptoms of dizzinessSymptoms of dizziness Decreasing urine outputDecreasing urine output Evidence of recurrent melaena / haematemesis Evidence of recurrent melaena / haematemesis

/ PR bleeding (haematochezia)/ PR bleeding (haematochezia)

ResuscitationResuscitation

Assess for signs of hypovolaemic shock Assess for signs of hypovolaemic shock A&BA&B

Large clots can block airwayLarge clots can block airway Risk of aspirationRisk of aspiration O2 15l O2 15l Attach monitoringAttach monitoring

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

inform blood bank inform blood bank IV fluids to maintain BP>100 systolicIV fluids to maintain BP>100 systolic

Start with up to 2l 0.9% Sodium Chloride STATStart with up to 2l 0.9% Sodium Chloride STAT Then progress to bloodThen progress to blood

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

BloodBlood

BloodBlood O NegativeO Negative

immediatelyimmediately shock not responding to IV fluidsshock not responding to IV fluids

Type specific (red label ...)Type specific (red label ...) 20 mins20 mins transient response, ongoing bleedtransient response, ongoing bleed

Fully X matchedFully X matched 40 mins plus40 mins plus responded to fluids, but significant blood lossresponded to fluids, but significant blood loss

Speak to lab technician they will know exact times!Speak to lab technician they will know exact times! Consider massive haemorrhage alert protocolConsider massive haemorrhage alert protocol

Massive Haemorrhage ProtocolMassive Haemorrhage Protocol Blood lossBlood loss

of 1 blood volume (5l) within 24hrsof 1 blood volume (5l) within 24hrs oror

of 50% blood volume (2.5l) within 3hrsof 50% blood volume (2.5l) within 3hrs oror

at rate of 150 mls/minat rate of 150 mls/min

Medical ManagementMedical Management StopStop

AntihypertensivesAntihypertensives NSAIDSNSAIDS AnticoagulantsAnticoagulants

GiveGive 10mg IV vitamin K if INR >1.310mg IV vitamin K if INR >1.3

ConsiderConsider 2mg IV Terlipressin (stat then QDS)2mg IV Terlipressin (stat then QDS) Broad spectrum antibiotics (e.g. Tazocin 4.5g tds)Broad spectrum antibiotics (e.g. Tazocin 4.5g tds) 40mg IV Omeprazole bd40mg IV Omeprazole bd 40mg oral Omeprazole od40mg oral Omeprazole od

Prescribing exercisePrescribing exercise

Emma Smith unstable in A&E resus with a Emma Smith unstable in A&E resus with a massive upper GI bleedmassive upper GI bleed

DOB 01/07/55DOB 01/07/55 Hospital Number AA111000Hospital Number AA111000 5 Carrington Close5 Carrington Close CoventryCoventry

PrescribePrescribe 3units red cells3units red cells

Causes of GI BleedCauses of GI Bleed 3 tasks!3 tasks!

Brainstorm all causes of GI bleedsBrainstorm all causes of GI bleeds

Divide into Upper & Lower GI causesDivide into Upper & Lower GI causes

Rank from most common to least commonRank from most common to least common

Causes - Upper GI (80%)Causes - Upper GI (80%) Peptic ulcer disease – 50%Peptic ulcer disease – 50% Erosive Gastritis / Oesophagitis – 18%Erosive Gastritis / Oesophagitis – 18% Varices – 10%Varices – 10% Mallory Weiss tear – 10%Mallory Weiss tear – 10% Cancer – Oesophageal or Gastric – 6%Cancer – Oesophageal or Gastric – 6% Coagulation disordersCoagulation disorders OtherOther

Aorto-enteric fistulaAorto-enteric fistula Benign tumoursBenign tumours Congenital – Ehlers-Danlos, Osler-Weber-RenduCongenital – Ehlers-Danlos, Osler-Weber-Rendu

Causes - Lower GI (20%)Causes - Lower GI (20%) Upper GI bleed!Upper GI bleed! Diverticular disease (angiodysplasia) - 60%Diverticular disease (angiodysplasia) - 60% Colitis (IBD & ischaemic) – 13%Colitis (IBD & ischaemic) – 13% Benign anorectal (haemorrhoids, fissures, Benign anorectal (haemorrhoids, fissures,

fistulas) – 11%fistulas) – 11% Malignancy – 9%Malignancy – 9% Coagulopathy – 4%Coagulopathy – 4% Angiodysplasia – 3%Angiodysplasia – 3% Post surgical / polypectomyPost surgical / polypectomy

Case 1Case 1

PC/HPCPC/HPC 18F 18F Vomited x4 tonight, now streaks of red blood on Vomited x4 tonight, now streaks of red blood on

3rd and 4th vomits3rd and 4th vomits Has been out with friends tonight, had “a few Has been out with friends tonight, had “a few

drinks”drinks” PMHPMH – Fit and well – Fit and well Drugs & AllergiesDrugs & Allergies – Nil – Nil O/EO/E Pulse 80 reg, BP 110/80 (no postural drop) Pulse 80 reg, BP 110/80 (no postural drop) Abdomen soft, non-tender, no organomegalyAbdomen soft, non-tender, no organomegaly PR - empty rectumPR - empty rectum Rest of examination normalRest of examination normal

Case 1Case 1 DiagnosisDiagnosis

Mallory Weiss tearMallory Weiss tear

SeveritySeverity MildMild

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

How can we predict mortality?How can we predict mortality?

Blatchford Score (pre endoscopy)Blatchford Score (pre endoscopy)

Predicts need for hospital based treatmentPredicts need for hospital based treatment Score of 6 or more over 50% risk of requiring Score of 6 or more over 50% risk of requiring

interventionintervention Lack of subjective variables (e.g. severity of systemic Lack of subjective variables (e.g. severity of systemic

diseases) diseases) Lack of a need for OGD to complete the score. Lack of a need for OGD to complete the score.

Systolic BPSystolic BP PulsePulse MelenaMelena SyncopeSyncope CoborbidityCoborbidity UreaUrea HbHb

Not as good as Rockall in predicting overall mortalityNot as good as Rockall in predicting overall mortality

Rockall Score (post endoscopy)Rockall Score (post endoscopy)ScoreScore

VariableVariable 00 11 22 33

AgeAge <60 years<60 years 60-79 years60-79 years >80 years>80 years

ShockShock No shockNo shock TachycardiaTachycardia HypotensionHypotension

Co-morbidityCo-morbidity No major No major comorbiditycomorbidity

CCF, IHD, major CCF, IHD, major comorbiditycomorbidity

Renal failure, Renal failure, liver failure, liver failure, malignancymalignancy

DiagnosisDiagnosis

(Post OGD)(Post OGD)

Mallory-Weiss Mallory-Weiss tear, no lesion tear, no lesion identified, no identified, no SRHSRH

All other All other diagnosesdiagnoses

Malignancy of Malignancy of upper GI tractupper GI tract

Major stigmata Major stigmata of recent of recent haemorrhagehaemorrhage


None or dark None or dark spot onlyspot only

Blood in GI Blood in GI tract, adherent tract, adherent clot, visible or clot, visible or spurting vesselspurting vessel

Endoscopy – Upper GI BleedsEndoscopy – Upper GI Bleeds Minor bleeds / unprovenMinor bleeds / unproven

Consider OP OGDConsider OP OGD Moderate bleedsModerate bleeds

IP OGD within 24hrsIP OGD within 24hrs Severe bleedsSevere bleeds

Urgent OGD,Urgent OGD, Inform Surgeons and Critical CareInform Surgeons and Critical Care

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

If fails, may need emergency surgeryIf fails, may need emergency surgery

Mallory Weiss tearMallory Weiss tear

Mallory Weiss tearMallory Weiss tear HxHx

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

vomitvomit

ExEx Normal examinationNormal examination

Minor Bleeds – AnorectalMinor Bleeds – Anorectal Bright red blood on toilet paper, not mixed with Bright red blood on toilet paper, not mixed with

stoolsstools Diagnosed by typical PR appearancesDiagnosed by typical PR appearances

HaemorrhoidsHaemorrhoids Feel “lump”, ItchFeel “lump”, Itch

Anal FissureAnal Fissure Anal pain +++ with motionsAnal pain +++ with motions

Fistula in anoFistula in ano Soiling on underwear, recurrent abscessesSoiling on underwear, recurrent abscesses

Anal FissureAnal Fissure

HaemorrhoidsHaemorrhoids

Fistula in anoFistula in ano

Moderate & Severe BleedsModerate & Severe Bleeds Resuscitation including TransfusionResuscitation including Transfusion Medical ManagementMedical Management HaemostasisHaemostasis Treatment of underlying diseaseTreatment of underlying disease

Investigations - WhyInvestigations - Why Confirm presence of bleedingConfirm presence of bleeding Allow safe blood transfusionAllow safe blood transfusion Plan treatmentPlan treatment

Assess degree of blood lossAssess degree of blood loss Locate bleedingLocate bleeding Confirm suspected diagnosisConfirm suspected diagnosis Assess extent (staging) of diseaseAssess extent (staging) of disease Assess risk factors for bleedingAssess risk factors for bleeding

BedsideBedside Faecal Occult Blood (FOB)Faecal Occult Blood (FOB)

Not commonly available now as bedside testNot commonly available now as bedside test Still used in lab for bowel cancer screeningStill used in lab for bowel cancer screening

ProctoscopyProctoscopy Anal canalAnal canal

Rigid SigmoidoscopyRigid Sigmoidoscopy Rectum and distal sigmoid colonRectum and distal sigmoid colon Up to 20cm maxUp to 20cm max

Blood testsBlood tests FBC FBC

Hb levelHb level ? Chronic microcytic anaemia? Chronic microcytic anaemia

LFTs & ClottingLFTs & Clotting Clotting disorders and risk factors for theseClotting disorders and risk factors for these Liver failure, and risk of varaciesLiver failure, and risk of varacies

Tumour MarkersTumour Markers CEA if suspected colon cancerCEA if suspected colon cancer Ca19.9, Ca125 & CEA if suspected gastric cancerCa19.9, Ca125 & CEA if suspected gastric cancer

G&S / CrossmatchG&S / Crossmatch Allows transfusionAllows transfusion

Imaging - location of bleedImaging - location of bleed All during active bleedAll during active bleed CT AngiogramCT Angiogram

Non invasive, sensitivity & specificity 85-90%Non invasive, sensitivity & specificity 85-90%

AngiogramAngiogram Bleeds >0.5 ml/minBleeds >0.5 ml/min Therapeutic & diagnosticTherapeutic & diagnostic

Red Cell Scan - Tc-99m RBC scintigraphy Red Cell Scan - Tc-99m RBC scintigraphy Slow volume bleeds, >0.1ml/minSlow volume bleeds, >0.1ml/min

Imaging – cause of bleedImaging – cause of bleed CT abdomen & pelvis with contrastCT abdomen & pelvis with contrast

Acutely unwell, for cause including ?colitisAcutely unwell, for cause including ?colitis Staging suspected cancersStaging suspected cancers

Barium EnemaBarium Enema Diverticular disease, Colon CancerDiverticular disease, Colon Cancer

CT ColonCT Colon As for Ba EnemaAs for Ba Enema

Barium meal / follow-throughBarium meal / follow-through Investigate possible small bowel causes (Crohn’s)Investigate possible small bowel causes (Crohn’s)

EndoscopyEndoscopy Rigid scopes – see bedside testsRigid scopes – see bedside tests OGD OGD (Oesophago-gastro-duodenoscopy, (Oesophago-gastro-duodenoscopy,

Gastroscopy, Upper GI endoscopy)Gastroscopy, Upper GI endoscopy) For all Upper GI bleedsFor all Upper GI bleeds

Flexible SigmoidoscopyFlexible Sigmoidoscopy Suspected left sided colonic bleedsSuspected left sided colonic bleeds

To splenic flexure, aprox 40-60cmTo splenic flexure, aprox 40-60cm ColonoscopyColonoscopy

Suspected right sided colonic bleedsSuspected right sided colonic bleeds Whole colon visualisedWhole colon visualised

SurgerySurgery Last resortLast resort When location not found, and ongoing When location not found, and ongoing

significant bleedsignificant bleed Can locate most proximal part of bowel Can locate most proximal part of bowel

with blood in lumen, & Limited resectionwith blood in lumen, & Limited resection If unclear, and colonic, occasionally total If unclear, and colonic, occasionally total

colectomycolectomy

Case StudiesCase Studies Small groups, same colour casesSmall groups, same colour cases For For Case 2Case 2, list and , list and justifyjustify::

Diagnosis & 2 main differentialsDiagnosis & 2 main differentials Severity of BleedSeverity of Bleed Blatchford or Rockall Score (pre endoscopy) if Blatchford or Rockall Score (pre endoscopy) if

appropriateappropriate Investigations & ManagementInvestigations & Management

Red case 2Red case 2 PC/HPCPC/HPC 73M 73M Bright red blood with dark clots in last 4 bowel Bright red blood with dark clots in last 4 bowel

motions (all today)motions (all today) Mixed with stool (liquid) initially, now only bloodMixed with stool (liquid) initially, now only blood No abdominal painNo abdominal pain PMHPMH – nil – nil DrugsDrugs – Movicol 1-2 satchets PRN – Movicol 1-2 satchets PRN O/E O/E BP 130/70 (no postural drop), P85, Hb 10.2BP 130/70 (no postural drop), P85, Hb 10.2 Abdomen soft, non tenderAbdomen soft, non tender PR – Bright red blood plus darker clots+ in rectumPR – Bright red blood plus darker clots+ in rectum

Case Red 2Case Red 2 DiagnosisDiagnosis

Diverticular bleedDiverticular bleed SeveritySeverity

ModerateModerate Blatchford ScoreBlatchford Score

n/a – only for upper GI bleedsn/a – only for upper GI bleeds Ix and MxIx and Mx

ABCDE resuscitationABCDE resuscitation Bloods (Hb level, exclude infection),?CT abdo, Bloods (Hb level, exclude infection),?CT abdo,

Flexi sig once settledFlexi sig once settled Observe, ?antibioticsObserve, ?antibiotics

Treatment – Lower GI BleedsTreatment – Lower GI Bleeds HaemostasisHaemostasis

Most stop spontaneously +/- medical Most stop spontaneously +/- medical managementmanagement

Angiogram EmbolisationAngiogram Embolisation Occasionally surgeryOccasionally surgery

Generalised colonic bleeds (eg colitis)Generalised colonic bleeds (eg colitis)

Endoscopy rarelyEndoscopy rarely Can’t see clearlyCan’t see clearly

Treatment of underlying diseaseTreatment of underlying disease Definitive treatment of Definitive treatment of

CancersCancers UlcersUlcers Diverticular diseaseDiverticular disease

Conservative, Medical or SurgicalConservative, Medical or Surgical Urgent or ElectiveUrgent or Elective

Diverticular DiseaseDiverticular Disease

Diverticular DiseaseDiverticular Disease HxHx

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

bloodblood Often out of the blueOften out of the blue Known historyKnown history

ExEx Abdomen usually non tenderAbdomen usually non tender Blood PR, no masses, no anorectal pathologyBlood PR, no masses, no anorectal pathology

Inflammatory Bowel DiseaseInflammatory Bowel Disease HxHx

Known IBDKnown IBD Loose motions, up to 20x/dayLoose motions, up to 20x/day Now mucus and blood, increased frequencyNow mucus and blood, increased frequency

ExEx ThinThin Tender abdomenTender abdomen Systemic signs of IBDSystemic signs of IBD

Ulcerative ColitisUlcerative Colitis

Crohn’s DiseaseCrohn’s Disease

Yellow 2Yellow 2 PC/HPCPC/HPC 70 F 70 F 24hrs increasing generalised abdo pain (now severe++) and 24hrs increasing generalised abdo pain (now severe++) and

diarrhoeadiarrhoea Now blood mixed with stools, bright and dark redNow blood mixed with stools, bright and dark red PMHPMH AF, otherwise well AF, otherwise well O/E O/E Pulse 130 Ireg Ireg, BP 110/60 lying, 90/50 sitting, Pulse 130 Ireg Ireg, BP 110/60 lying, 90/50 sitting, RR 24, looks pale and clammy, RR 24, looks pale and clammy, Abdomen soft, no localised tendernessAbdomen soft, no localised tenderness PR – blood mixed with mucus and liquid stool on fingerPR – blood mixed with mucus and liquid stool on finger ABG – Lactate 5.1, pO2 12.4, pCO2 3.0, pH 7.35ABG – Lactate 5.1, pO2 12.4, pCO2 3.0, pH 7.35

Case Yellow 2Case Yellow 2 DiagnosisDiagnosis

Ischaemic colitisIschaemic colitis SeveritySeverity

SevereSevere Blatchford scoreBlatchford score

n/an/a Ix and MxIx and Mx

ABCDE resuscitationABCDE resuscitation ECG, Rigid sigmoidoscopy, ECG, Rigid sigmoidoscopy, Bloods (Hb, Trop I, U&Es, inflammatory markers),Bloods (Hb, Trop I, U&Es, inflammatory markers), CT abdomenCT abdomen ColonoscopyColonoscopy NBM, IVI, Antibiotics, +/- SurgeryNBM, IVI, Antibiotics, +/- Surgery

Ischaemic ColitisIschaemic Colitis HxHx

AF / IHDAF / IHD Generalised painGeneralised pain Colitic symptomsColitic symptoms Deteriorating rapidlyDeteriorating rapidly

ExEx ““Pain out of proportion with signs”Pain out of proportion with signs” No localised signs (until perforation)No localised signs (until perforation) AcidosisAcidosis

Case Blue 2Case Blue 2 PC/HPCPC/HPC 45 M attends A&E 45 M attends A&E 3 episodes haematemesis today, bright red blood++3 episodes haematemesis today, bright red blood++ no other complaints from patientno other complaints from patient PMH PMH – admits nil– admits nil SHSH – 4 cans strong larger / day – 4 cans strong larger / day DrugsDrugs – Thiamine, Vit B Co Strong – Thiamine, Vit B Co Strong O/E O/E HR 110bpm reg, BP 98/60, Urea 6.6, Hb119g/lHR 110bpm reg, BP 98/60, Urea 6.6, Hb119g/l mildly confused (GCS 14/15)mildly confused (GCS 14/15) Jaundiced, 3x spider nevi on chest and abdomenJaundiced, 3x spider nevi on chest and abdomen Abdomen soft, non tender. RUQ tender mass, smooth, 1 Abdomen soft, non tender. RUQ tender mass, smooth, 1

finger breath below costal margin, moves with respirationfinger breath below costal margin, moves with respiration PR – Dark red blood in rectum, no visible stoolsPR – Dark red blood in rectum, no visible stools

Case Blue 2Case Blue 2 DiagnosisDiagnosis

Bleeding varicesBleeding varices SeveritySeverity

SevereSevere Blatchford ScoreBlatchford Score

BP 2, P 1, Melena 1, syncope 0, Comorbidities 0, BP 2, P 1, Melena 1, syncope 0, Comorbidities 0, Urea 2, Hb 3 = 9Urea 2, Hb 3 = 9

Ix and MxIx and Mx ABCDE resuscitation, inc up to 2l fluids, FFP, ? blood ABCDE resuscitation, inc up to 2l fluids, FFP, ? blood Terlipressin, IV Antibiotics, ?Vitamin K, Urgent senior Terlipressin, IV Antibiotics, ?Vitamin K, Urgent senior

r/v, urgent endoscopy (within 8hrs)r/v, urgent endoscopy (within 8hrs)

Case Blue 2Case Blue 2

OGD Results:OGD Results: Large oesophageal Large oesophageal

varices, no active varices, no active bleeding. bleeding.

Clots in stomach. Clots in stomach. Varices banded.Varices banded.

What is the Rockall What is the Rockall Score?Score?

Rockall Score Rockall Score ScoreScore

Post endoscopy?Post endoscopy?




Co-morbidityCo-morbidity No major No major cormorbiditycormorbidity



DiagnosisDiagnosis








Blood in GI tract, Blood in GI tract, adherent clot, adherent clot, visible or visible or spurting vesselspurting 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

Oesophageal VaricesOesophageal Varices HxHx

Known liver diseaseKnown liver disease Known varicesKnown varices High alcohol intakeHigh alcohol intake

ExEx Stigmata of liver diseaseStigmata of liver disease Smell of alcohol on breathSmell of alcohol on breath

Yellow scleraYellow sclera

Caput MedusaeCaput Medusae

GynaecomastiaGynaecomastia

Palmar erythemaPalmar erythema

Dupuytren’s contractureDupuytren’s contracture

Case Green 2Case Green 2 PC/HPCPC/HPC 35M, GP admission to CDU35M, GP admission to CDU Diarrhoea today, and feeling a little faint at times, but hasn’t Diarrhoea today, and feeling a little faint at times, but hasn’t

passed out. Mild epigastric pain 1/7, settles with antacids.passed out. Mild epigastric pain 1/7, settles with antacids. PMH –PMH – Sports injury 10/7 ago, ?ACL damage Sports injury 10/7 ago, ?ACL damage Drugs Drugs – nil regular, on pain relief for knee– nil regular, on pain relief for knee AllergiesAllergies - nil - nil O/E O/E Pulse 100 reg, BP 110/60, (lying), 80/40 (standing)Pulse 100 reg, BP 110/60, (lying), 80/40 (standing) Tender epigastrum, no guarding, slightly distended, no Tender epigastrum, no guarding, slightly distended, no

organomegalyorganomegaly PR – black, tarry motion, no red blood or faecesPR – black, tarry motion, no red blood or faeces Other examination normalOther examination normal

Case Green 2Case Green 2 DiagnosisDiagnosis

Duodenal UlcerDuodenal Ulcer SeveritySeverity

SevereSevere Rockall ScoreRockall Score

Age 0, Shock 2, Co-morbidity 0= Age 0, Shock 2, Co-morbidity 0= Total 2Total 2 Ix and MxIx and Mx

ABCDE, 2L fluids, +/- bloodABCDE, 2L fluids, +/- blood IV Omeprazole, endoscopy within 24hrs, close IV Omeprazole, endoscopy within 24hrs, close

monitoring, ?Erect CXRmonitoring, ?Erect CXR

Case Green 2Case Green 2 OGD after 2hrs (pt OGD after 2hrs (pt

deteriorated)deteriorated) Blood in stomach ++ Blood in stomach ++ Large duodenal ulcer, Large duodenal ulcer,

spurting bloodspurting blood

What is the new What is the new Rockall Score?Rockall Score?

Rockall Score (Upper GI only)Rockall Score (Upper GI only)ScoreScore

Post endoscopy score?Post endoscopy score?




Co-morbidityCo-morbidity No major No major cormorbiditycormorbidity



DiagnosisDiagnosis








Blood in GI tract, Blood in GI tract, adherent clot, adherent clot, visible or visible or spurting vesselspurting vesselPre 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

Gastric and Duodenal UlcersGastric and Duodenal Ulcers

GastritisGastritis

Peptic ulcers and ErosionsPeptic ulcers and Erosions HxHx

Associated with typical painAssociated with typical pain NSAID useNSAID use Previous gastritis / ulcersPrevious gastritis / ulcers Stress (including operations)Stress (including operations)

ExEx Epigastric tenderness / guardingEpigastric tenderness / guarding

Perforated ulcersPerforated ulcers Ulcers rarely bleed and perforate Ulcers rarely bleed and perforate

simultaneouslysimultaneously Suspect perforation if any abdominal Suspect perforation if any abdominal

guardingguarding Localised epigastric guardingLocalised epigastric guarding Generalised peritonitisGeneralised peritonitis

If suspiciousIf suspicious get Erect CXRget Erect CXR Surgical inputSurgical input

Other BleedsOther Bleeds

Post op ComplicationsPost op Complications Very rareVery rare Must be considered if Must be considered if

recent interventionrecent intervention More commonly, re-More commonly, re-

bleeds post bleeds post haemostatic haemostatic interventionsinterventions

Can be very large Can be very large bleeds, clots+++bleeds, clots+++

Dieulafoy’s lesionDieulafoy’s lesion AV malformationAV malformation Very difficult to see at Very difficult to see at

endoscopyendoscopy Frequently re-bleeds Frequently re-bleeds

after interventionafter intervention Can be missed, so can Can be missed, so can

bleed after “negative” bleed after “negative” endoscopyendoscopy

Colon CancerColon Cancer

Colorectal MalignancyColorectal Malignancy HxHx

Weight loss, loss of appetite, lethargyWeight loss, loss of appetite, lethargy Right sided – often only iron deficiency anaemiaRight sided – often only iron deficiency anaemia Left side – change in bowel habit, blood mixed Left side – change in bowel habit, blood mixed

with stool, mucus, tenesmuswith stool, mucus, tenesmus ExEx

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

Gastric CancerGastric Cancer

Oesophageal cancerOesophageal cancer

Oesophageal & Gastric Oesophageal & Gastric MalignanciesMalignancies

HxHx Weight loss, loss of appetite, general lethargyWeight loss, loss of appetite, general lethargy DysphagiaDysphagia Vomiting ++Vomiting ++ Known malignancyKnown malignancy Recent stent insertionRecent stent insertion

ExEx EmaciatedEmaciated Palpable craggy liver edgePalpable craggy liver edge Palpable neck LN (rare)Palpable neck LN (rare) Visible metastases (rare)Visible metastases (rare)

Summary (1)Summary (1) Colour of blood important for location of Colour of blood important for location of

bleedbleed Assess severity of bleed (including Rockall Assess severity of bleed (including Rockall

Score) to decide urgency of managementScore) to decide urgency of management Simultaneous Resuscitation, investigations Simultaneous Resuscitation, investigations

& management if unwell& management if unwell Targeted investigations for less sick Targeted investigations for less sick

patientspatients

Summary (2)Summary (2)

Likely diagnosis from history and Likely diagnosis from history and examinationexamination

Use guidelines / pathways to aid Use guidelines / pathways to aid managementmanagement

ASK FOR HELP when needed!!!ASK FOR HELP when needed!!!

ANY QUESTIONS?ANY QUESTIONS?

gastrointestinal haemorrhage rebecca shields clinical teaching fellow uhcw

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