Gastrointestinal
Haemorrhage
Rebecca Shields
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
Recognise a GI Bleed
History
 Amount
 Difficult
 Usually under estimated
 Appearance
 What colours can blood be?
 Why does it change colour?
 Duration
 Associated Sx
 Risk factors
Blood loss exercise
 Estimate the volume of blood loss in each
picture
 What colour can blood be?
 Why does it change?
 Always visible?
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
 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
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:
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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)
Resuscitation
 Assess for signs of hypovolaemic shock
 A&B
 Large clots can block airway
 Risk of aspiration
 O2 15l
 Attach monitoring
Circulation - Interventions
 2 large bore IV cannulae (14 or 16 G)
 Send blood for FBC, clotting, G&S or Xmatch, 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
D
E
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
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2mg IV Terlipressin (stat then QDS)
Broad spectrum antibiotics (e.g. Tazocin 4.5g tds)
40mg IV Omeprazole bd
40mg oral Omeprazole od
Prescribing exercise
 Emma Smith unstable in A&E resus with a
massive upper GI bleed
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DOB 01/07/55
Hospital Number AA111000
5 Carrington Close
Coventry
 Prescribe
 3units red cells
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%)
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Peptic ulcer disease – 50%
Erosive Gastritis / Oesophagitis – 18%
Varices – 10%
Mallory Weiss tear – 10%
Cancer – Oesophageal or Gastric – 6%
Coagulation disorders
Other
 Aorto-enteric fistula
 Benign tumours
 Congenital – Ehlers-Danlos, Osler-Weber-Rendu
Causes - Lower GI (20%)
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Upper GI bleed!
Diverticular disease (angiodysplasia) - 60%
Colitis (IBD & ischaemic) – 13%
Benign anorectal (haemorrhoids, fissures,
fistulas) – 11%
Malignancy – 9%
Coagulopathy – 4%
Angiodysplasia – 3%
Post surgical / polypectomy
Case 1
 PC/HPC 18F
 Vomited x4 tonight, now streaks of red blood on
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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?
Blatchford Score (pre endoscopy)
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Predicts need for hospital based treatment
Score of 6 or more over 50% risk of requiring
intervention
Lack of subjective variables (e.g. severity of systemic
diseases)
Lack of a need for OGD to complete the score.
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Systolic BP
Pulse
Melena
Syncope
Coborbidity
Urea
Hb
Not as good as Rockall in predicting overall mortality
Rockall Score (post endoscopy)
Score
Variable
0
1
2
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
Co-morbidity
No major
comorbidity
Diagnosis
(Post OGD)
Mallory-Weiss
tear, no lesion
identified, no
SRH
Major stigmata
of recent
haemorrhage
(Post OGD)
None or dark
spot only
CCF, IHD, major
comorbidity
All other
diagnoses
Malignancy of
upper GI tract
Blood in GI tract,
adherent clot,
visible or
spurting vessel
3
Renal failure,
liver failure,
malignancy
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
Investigations - Why
 Confirm presence of bleeding
 Allow safe blood transfusion
 Plan treatment
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Assess degree of blood loss
Locate bleeding
Confirm suspected diagnosis
Assess extent (staging) of disease
Assess risk factors for bleeding
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
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)
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
Case Studies
 Small groups, same colour cases
 For Case 2, list and justify:
 Diagnosis & 2 main differentials
 Severity of Bleed
 Blatchford or Rockall Score (pre endoscopy) if
appropriate
 Investigations & Management
Red case 2
 PC/HPC 73M
 Bright red blood with dark clots in last 4 bowel
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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
 Blatchford 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
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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
 Blatchford score
 n/a
 Ix and Mx
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ABCDE resuscitation
ECG, Rigid sigmoidoscopy,
Bloods (Hb, Trop I, U&Es, inflammatory markers),
CT abdomen
Colonoscopy
NBM, IVI, Antibiotics, +/- Surgery
Ischaemic Colitis
 Hx
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AF / IHD
Generalised pain
Colitic symptoms
Deteriorating rapidly
 Ex
 “Pain out of proportion with signs”
 No localised signs (until perforation)
 Acidosis
Case Blue 2
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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, Urea 6.6, Hb119g/l
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
 Blatchford Score
 BP 2, P 1, Melena 1, syncope 0, Comorbidities 0,
Urea 2, Hb 3 = 9
 Ix and Mx
 ABCDE resuscitation, inc up to 2l fluids, FFP, ?
blood
 Terlipressin, IV Antibiotics, ?Vitamin K, Urgent
senior r/v, urgent endoscopy (within 8hrs)
Case Blue 2
 OGD Results:
 Large oesophageal
varices, no active
bleeding.
 Clots in stomach.
 Varices banded.
 What is the Rockall
Score?
Rockall Score
Score
Post endoscopy?
Variable
0
1
2
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
Co-morbidity
No major
cormorbidity
Diagnosis
(Post OGD)
Mallory-Weiss
tear, no lesion
identified, no
SRH
Major stigmata
of recent
haemorrhage
(Post OGD)
None or dark
spot only
CCF, IHD, major
comorbidity
All other
diagnoses
Pre OGD Score
0-1 next available list (Mortality <2.5%)
>=2 urgent OGD (Mortality 5%)
3
Renal failure,
liver failure,
malignancy
Malignancy of
upper GI tract
Blood in GI tract,
adherent clot,
visible or
spurting vessel
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
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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
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
Co-morbidity
No major
cormorbidity
Diagnosis
(Post OGD)
Mallory-Weiss
tear, no lesion
identified, no
SRH
Major stigmata
of recent
haemorrhage
Pre(Post
OGDOGD)
Score
None or dark
spot only
CCF, IHD, major
comorbidity
All other
diagnoses
0-1 next available list (Mortality <2.5%)
>=2 urgent OGD (Mortality 5%)
3
Renal failure,
liver failure,
malignancy
Malignancy of
upper GI tract
Blood in GI tract,
adherent clot,
visible or
OGD
Score
spurting
vessel
Post
<3 good prognosis, early discharge
>8 high risk of death
Gastric and Duodenal Ulcers
Gastritis
Peptic ulcers and Erosions
 Hx
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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, rebleeds 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
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
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Palpable mass (abdominal / PR)
Visible weight loss
Craggy liver edge
May be normal
Gastric Cancer
Oesophageal cancer
Oesophageal & Gastric
Malignancies
 Hx
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Weight loss, loss of appetite, general lethargy
Dysphagia
Vomiting ++
Known malignancy
Recent stent insertion
 Ex
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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?