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Gastrointestinal Gastrointestinal HaemorrhageHaemorrhage
Joel BurtonJoel Burton
Clinical Teaching FellowClinical Teaching Fellow
UHCWUHCW
Acute Block Objectives - OutlineAcute Block Objectives - OutlineExplain the likely Explain the likely causes of upper GI bleedscauses of upper GI bleeds from from history and examinationhistory and examinationDemonstrate an understanding of Demonstrate an understanding of initial initial managementmanagement of acute upper GI bleeds of acute upper GI bleedsDistinguish 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 bleedsbleedsAssessment of the acutely unwell patientAssessment of the acutely unwell patientResuscitationResuscitation
Recognise a GI BleedRecognise a GI Bleed
HistoryHistory
Appearance Appearance What colours can blood be?What colours can blood be? Why does it change colour?Why does it change colour?
AmountAmount DifficultDifficult Usually under estimatedUsually under estimated
DurationDuration Associated SxAssociated Sx Risk factorsRisk factors
GI bleedingGI bleeding
What colour can blood be?What colour can blood be?
Why does it change?Why does it change?
Always visible?Always visible?
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
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 Send blood for FBC, clotting, G&S or crossmatchcrossmatch
Fluids or blood?Fluids or blood?
Urinary catheter?Urinary catheter?
BloodBlood
Blood samplingBlood sampling Group and saveGroup and save
This will not get you blood!This will not get you blood!
CrossmatchCrossmatch This will actually get you blood!This will actually get you blood!
BloodBlood O NegativeO Negative
immediatelyimmediately Type specific Type specific
20 mins20 mins
Fully X matchedFully X matched 40 mins plus40 mins plus
Consider massive haemorrhage alert protocolConsider massive haemorrhage alert protocol
Massive Haemorrhage ProtocolMassive Haemorrhage Protocol Blood lossBlood loss
of 2000ml blood loss in 2 hours, orof 2000ml blood loss in 2 hours, or Pulse >120/min, SBP <80mmHg, orPulse >120/min, SBP <80mmHg, or at rate of 150 mls/min, orat rate of 150 mls/min, or Massive trauma situationsMassive trauma situations
Massive Haemorrhage ProtocolMassive Haemorrhage Protocol Emergency call via switchboardEmergency call via switchboard At UHCW it gets you:At UHCW it gets you:
StaffStaff Pack 1Pack 1 Pack 2Pack 2
Massive Haemorrhage ProtocolMassive Haemorrhage Protocol StaffStaff
Team leader (consultant in relevant specialty)Team leader (consultant in relevant specialty) Runner (porter)Runner (porter) Communication leadCommunication lead IV access and sample takerIV access and sample taker Senior surgeonSenior surgeon Senior ITU & ODPSenior ITU & ODP Receptionist (in ED)Receptionist (in ED)
Massive Haemorrhage ProtocolMassive Haemorrhage Protocol Pack onePack one
4 units red cells4 units red cells 2 units FFP2 units FFP
Pack twoPack two 4 units red cells4 units red cells 4 units FFP4 units FFP 1 unit platelets1 unit platelets
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 ED resus with a Emma Smith unstable in ED 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 Has been out with friends tonight, had ““a few a few
drinksdrinks”” 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 dischargeSenior r/v with view to discharge
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 have 50% risk of requiring Score of 6 or more have 50% risk of requiring
interventionintervention No subjective variables (e.g. severity of systemic No subjective variables (e.g. severity of systemic
diseases) diseases) No need for OGD to complete the score. No need for OGD to complete the score.
Systolic BPSystolic BP PulsePulse MelenaMelena SyncopeSyncope CoborbidityCoborbidity UreaUrea HbHb
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 Small volume blood ““streaksstreaks””, mixed with , mixed with
vomitvomit
ExEx Normal examinationNormal examination
Minor Bleeds – AnorectalMinor Bleeds – Anorectal Bright red blood on toilet paper, not mixed Bright red blood on toilet paper, not mixed
with stoolswith stools Diagnosed by typical PR appearancesDiagnosed by typical PR appearances
Anal FissureAnal Fissure
HaemorrhoidsHaemorrhoids
Fistula in anoFistula in ano
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
Group and saveGroup and save
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 (CrohnInvestigate possible small bowel causes (Crohn’’s)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 each caseeach case, list and , list and justifyjustify::
Diagnosis & 2 main differentialsDiagnosis & 2 main differentials Severity of BleedSeverity of Bleed Blatchford or Rockall Score if appropriateBlatchford or Rockall Score if appropriate Investigations & ManagementInvestigations & Management
Red CaseRed Case 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 settled to confirm diagnosisFlexi sig once settled to confirm diagnosis Observe, Antibiotics if diverticulitisObserve, Antibiotics if diverticulitis
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 CanCan’’t see clearlyt see clearly
Diverticular Diverticular DiseaseDisease
HxHx Prone to constipationProne to constipation Loose motion, then blood mixed in, then only Loose motion, then blood mixed in, then only
bloodblood 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
Yellow CaseYellow Case DiagnosisDiagnosis
Ischaemic colitisIschaemic colitis SeveritySeverity
SevereSevere Blatchford scoreBlatchford score
n/an/a Ix and MxIx and Mx
ABCDE resuscitationABCDE resuscitation ECG, ECG, Bloods (Hb, U&Es, inflammatory markers),Bloods (Hb, U&Es, inflammatory markers), CT abdomen with contrastCT abdomen with contrast NBM, IVI, Antibiotics, +/- Surgery (or embolectomy by NBM, IVI, Antibiotics, +/- Surgery (or embolectomy by
interventional radiologyinterventional radiology
Ischaemic ColitisIschaemic Colitis HxHx
AF / IHDAF / IHD Generalised painGeneralised pain Colitic symptomsColitic symptoms Deteriorating rapidlyDeteriorating rapidly
ExEx ““Pain out of proportion with signsPain out of proportion with signs”” No localised signs (until perforation)No localised signs (until perforation) AcidosisAcidosis
Blue CaseBlue Case
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, with blood/FFPABCDE resuscitation, with blood/FFP IV antibiotics and vitamin KIV antibiotics and vitamin K Endoscopy for bandingEndoscopy for banding Consider terlipressinConsider terlipressin
Blue CaseBlue Case
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
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 cormorbiditycormorbidity
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
(Post OGD)(Post OGD)
None or dark None or dark spot onlyspot only
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
Green CaseGreen Case DiagnosisDiagnosis
Duodenal UlcerDuodenal Ulcer SeveritySeverity
SevereSevere Blachford scoreBlachford score
10 (Systolic BP 3, pulse 1, melena 1, syncope 0, 10 (Systolic BP 3, pulse 1, melena 1, syncope 0, comorbidity 0, urea 2, Hb 3)comorbidity 0, urea 2, Hb 3)
Ix and MxIx and Mx ABCDE, resuscitate with bloodABCDE, resuscitate with blood IV Omeprazole, endoscopy within 24hrs and IV Omeprazole, endoscopy within 24hrs and
close monitoringclose monitoring
Green CaseGreen Case 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 Rockall What is the Rockall Score?Score?
Rockall Score Rockall Score 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 cormorbiditycormorbidity
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
(Post OGD)(Post OGD)
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
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
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
Case 2Case 2
DiagnosisDiagnosis Lower GI bleed – Lower GI bleed – ‘‘chronicchronic’’ Secondary to caecal carcinomaSecondary to caecal carcinoma
Ix and MxIx and Mx Transfuse for Hb >7Transfuse for Hb >7 CT scanCT scan ColonoscopyColonoscopy Definitive treatment for cancer (Right Definitive treatment for cancer (Right
Hemicolectomy)Hemicolectomy)
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
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)
SummarySummary Colour of blood important for location of Colour of blood important for location of
bleedbleed Assess severity of bleed (including Assess severity of bleed (including
Blachford Score) to decide urgency of Blachford Score) to decide urgency of managementmanagement
Simultaneous Resuscitation, investigations Simultaneous Resuscitation, investigations & management if unwell& management if unwell
Targeted investigations for less sick patientsTargeted investigations for less sick patients
ANY QUESTIONS?ANY QUESTIONS?