gastrointestinal haemorrhage pre lecture handout
TRANSCRIPT
Gastrointestinal Haemorrhage
Pre Lecture Handout
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 Understand resuscitation of bleeding patient, including use of
fluids and blood List common causes of GI bleeds Know symptom complexes that clinically differentiate these
causes Think about different types of investigations and what information
can be obtained from them Attitudes
Appreciate knowing purpose of investigations allows correct choice of investigation
Outline
Recognising GI Bleeds Causes of GI Bleeds Features of specific Lower GI Bleeds Investigation of Lower GI Bleeds
Upper GI Bleeds in Case studies in week 5
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
List different colours blood may be in vomit or stool
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
Case 1
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
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
Case 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
Ischemic Colitis
Hx AF / IHD Generalised pain Colitic symptoms Very unwell
Ex “pain out of proportion with signs” No localised signs (until perforation) Acidosis
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
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 (mild) diffusely Abdomen - Vague Mass RIF, non tender PR – soft brown stool on examining finger.
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
Management
Resuscitation Investigations to confirm cause of bleed Specific treatment of cause
Investigations may be IP or OP
Resuscitation
Airway Breathing Circulation Disability Exposure
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
Fluid challenge, if shocked 2L warmed crystalloid
If continued shock: blood, clotting factors 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
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, and; No evidence of gross rectal bleeding, and; An obvious anorectal source of bleeding on rectal
examination +/- rigid sigmoidoscopy.
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
Treatment
Haemostasis Most stop spontaneously +/- medical managment Angiogram Embolisation Occasionally surgery
Generalised colonic bleeds (eg colitis) Endoscopy rarely
Treatment of underlying disease Medical or Surgical Urgent or Elecitve
Summary
Colour of blood important for location of bleed ABCDE resuscitation Likely diagnosis from history and examination Targeted investigations Allows
Planning of treatment Priorities