Gastrointestinal Haemorrhage

1. Gastrointestinal Haemorrhage Pre Lecture Handout

2. 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

3. 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

4. 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

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?

6. Colours of Blood • List different colours blood may be in vomit or stool

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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 IregIreg, 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

15. Ischemic Colitis • Hx • AF / IHD • Generalised pain • Colitic symptoms • Very unwell • Ex • “pain out of proportion with signs” • No localised signs (until perforation) • Acidosis

16. 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

17. 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.

18. 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

19. Management • Resuscitation • Investigations to confirm cause of bleed • Specific treatment of cause • Investigations may be IP or OP

20. Resuscitation • Airway • Breathing • Circulation • Disability • Exposure

21. Circulation – recognising shocked patients • Pale • Clammy skin • High Cap Refill (>2s) • Weak pulse • Tachycardia (NB beta blockers) • Hypotention • (High resp rate) • (Confusion)

22. 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

23. 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

24. 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

25. 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)

26. 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.

27. 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

28. Investigations - Types • Bedside • Blood tests • Imaging • Endoscopy • Surgery

29. 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

30. Summary • Colour of blood important for location of bleed • ABCDE resuscitation • Likely diagnosis from history and examination • Targeted investigations • Allows • Planning of treatment • Priorities