gastrointestinal haemorrhage phil polson clinical teaching fellow uhcw
TRANSCRIPT
Gastrointestinal Haemorrhage
Phil Polson
Clinical Teaching Fellow
UHCW
Acute Block Objectives - Outline
GI Bleeds Explain the likely causes of upper GI bleeds from history
and examination. Demonstrate an understanding of initial 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 unwell patient Resuscitation
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
History & Examination
History & Examination
Working DiagnosisWorking
Diagnosis
Recognise a GI Bleed
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 ground
Small Bowel – Digestive enzymes Bright Red Dark Red
Colon – Bacteria Bright Red Dark Red Black
PR Bleeds (haematochezia)
Upper GI Black, Tar-like (Malaena)
Caecum / Transverse colon Dark Red, Loose stools Mixed with stools
Sigmoid / Anus / Rectum Bright red Mixed or separate
COULD ALL BE MASSIVE UPPER GI BLEED
Consider occult GI blood loss when:
Unexplained anaemia
Sudden hypotension and tachycardia, often fluid responsive
Shocked patient - PMH of GI bleeds or risk factors
Causes of GI Bleed
3 tasks! Brainstorm all causes of GI bleeds
Divide into Upper & Lower GI causes
Rank from most common to least common
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
General Management
Urgency of Management
Resuscitation Medical Management Haemostasis Treatment of underlying disease
Urgency of Management
Severe bleeds Resuscitation IP investigation +/- treatment
Moderate bleeds IP observation until 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 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)
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
Ix and Mx Senior r/v with view to discharge and OP OGD
How can we predict mortality?
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 comorbidity
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 Minor bleeds / unproven
Consider OP OGD Moderate bleeds
IP OGD within 24hrs Severe bleeds
Urgent OGD, Inform Surgeons and Critical Care
Suspected Variceal bleed Continued bleeding, >4u blood to keep BP >100 Continuing fresh melaena / haematemesis Re-bleed / unstable post resuscitation
If fails, may need emergency surgery
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
Minor Bleeds – 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 ano
Soiling on underwear, recurrent abscesses
Anal Fissure
Haemorrhoids
Fistula in ano
Moderate & Severe Bleeds
Resuscitation including Transfusion Medical Management Haemostasis Treatment of underlying disease
Resuscitation
A B C D E
Airway & Breathing
Large clots can block airway
Reduced conscious level (shock/encephalopathy)
Risk of aspiration
Give 15l/min oxygen via face mask
Circulation – recognising shocked patients
Pale Clammy skin High Cap Refill (>2s) Weak pulse Tachycardia (NB beta blockers) Hypotension (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,
inform blood bank IV fluids to maintain BP>100 systolic
Start with up to 2l 0.9% Sodium Chloride STAT Then progress to blood
IV FFP if variceal bleed suspected or INR>1.3 Urinary catheter
Blood
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
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
Investigations - Why
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 on handout
Case Studies
Small groups, same colour cases For Case 2, list and justify:
Diagnosis & 2 main differentials Severity of Bleed Rockall Score (pre endoscopy) if appropriate Investigations & Management
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 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
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 history
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
Ischaemic colitis Severity
Severe Rockall Score
n/a Ix and Mx
ABCDE resuscitation ECG, Rigid sigmoidoscopy, Bloods (Hb, Trop I, U&Es, inflammatory markers), CT abdomen Colonoscopy NBM, IVI, Antibiotics, +/- Surgery
Ischaemic Colitis
Hx AF / IHD Generalised pain Colitic symptoms Deteriorating rapidly
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 varices
Severity Severe
Rockall Score Age 0, Shock 2, Co-morbidity 3 = Total 5
Ix and Mx ABCDE resuscitation, inc up to 2l fluids, FFP, ? blood Terlipressin, Tazocin, ?Vitamin K, Urgent senior r/v,
urgent endoscopy
Rockall Score (Upper GI only)Score
Pre endoscopy 5
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
Case Blue 2
OGD Results: Large oesophageal
varices, no active bleeding.
Clots in stomach. Varices banded.
What is the new Rockall Score?
Rockall Score (Upper GI only)Score
Post endoscopy?
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
Oesophageal Varices
Hx Known liver disease Known varices High alcohol intake
Ex Stigmata of liver disease Smell of alcohol on breath
Yellow sclera
Caput Medusae
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 epigastrum, no guarding, slightly distended, no
organomegaly PR – black, tarry motion, no red blood or faeces 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
Case Green 2
OGD after 2hrs (pt deteriorated) Blood in stomach ++ Large duodenal ulcer,
spurting blood
What is the new Rockall Score?
Rockall Score (Upper GI only)Score
Post endoscopy 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
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
Other Bleeds
Post op Complications Very rare Must be considered if
recent intervention More commonly, re-
bleeds post haemostatic 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) Abdomen - Vague mass RIF, non tender PR – soft brown stool.
Case 3 Diagnosis
Lower GI bleed – ‘chronic’ Secondary to caecal carcinoma
Ix and Mx Slow transfusion, +/- diuretic CT scan Colonoscopy Definitive treatment for cancer (Right Hemicolectomy)
Colon Cancer
Colorectal Malignancy
Hx Weight loss, loss of appetite, lethargy Right sided – often only iron deficiency anaemia Left side – change in bowel habit, blood mixed with
stool, mucus, tenesmus Ex
Palpable mass (abdominal / PR) Visible weight loss Craggy liver edge May be normal
Gastric Cancer
Oesophageal cancer
Oesophageal & Gastric Malignancies
Hx Weight loss, loss of appetite, general lethargy Dysphagia Vomiting ++ Known malignancy Recent stent insertion
Ex Emaciated Palpable craggy liver edge Palpable neck LN (rare) Visible metastases (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 Use guidelines / pathways to aid
management ASK FOR HELP when needed!!!
ANY QUESTIONS?
Appendix – Investigations for GI bleed patients
Bedside
Faecal Occult 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
Laing C J et al. Radiographics 2007;27:1055-1070
©2007 by Radiological Society of North America
CT Angiogram
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 (Crohn’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
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