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?