Gastrointestinal Haemorrhage Mrs Esther Mitchell Clinical Teaching Fellow.
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Transcript of Gastrointestinal Haemorrhage Mrs Esther Mitchell Clinical Teaching Fellow.
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Gastrointestinal Haemorrhage
Mrs Esther Mitchell
Clinical Teaching Fellow
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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
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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 List common causes of lower GI bleeds Know symptom complexes that clinically differentiate these
causes Know the initial management of upper GI bleed patients List features on history and examination that suggest Varaceel
bleeds List 5 other causes of upper GI bleed Describe the distinguishing features of these other presentations
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Today’s Objectives continued Knowledge continued
Understand resuscitation of bleeding patient, including use of fluids and blood
Think about different types of investigations and what information can be obtained from them
Skills Fill in an upper GI bleed care pathway Be able to calculate a Rockal score Prescribe blood and IV drugs correctly
Attitudes Appreciate knowing purpose of investigations allows correct
choice of investigation Be aware of how serious upper GI bleeds can be Give GI bleed patients appropriate priority
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Outline
Patient Pathways General principles & Worked Examples
Recognising a GI Bleed Causes of GI Bleeds Management Investigations
Including Case Study Group work sessions
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Patient Pathway – “Normal”
Treatment
Presentation
History & Examination
Provisional Diagnosis
Investigations
Specific Diagnosis
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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
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Recognise a GI Bleed
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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?
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Colours of Blood
Colour Vomit Stool
Bright Red √ √
Dark Red x √
Green x x
Black x √
Brown √ x ?
No motion / vomit ? ?
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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
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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
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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
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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
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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%
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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
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Management
Urgency of Management
Resuscitation including Transfusion Medical Management Haemostasis Treatment of underlying disease
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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
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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)
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Low risk patients
Consider for discharge or non-admission 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)
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Introduction to Upper GI Bleed Pathway
3 minutes, working individually Fill in pathway for Case 1 Need:
coloured case study sheet (any colour) Upper GI bleed pathway
Use your imagination to fill in details not stated!!!
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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
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Case 1
Diagnosis Mallory Weiss tear
Severity Mild
Rockall Score Age 0, Shock 0, co-morbidity 0 = 0
Ix and Mx Senior r/v with view to discharge and OP OGD
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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 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
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Endoscopy – Upper GI Bleeds
Severe bleeds Urgent OGD, inform Surgeons and Critical Care
Suspected Varceal bleed Continued bleeding, >4u blood to keep BP >100 Continuing fresh melaena / haematemesis Re-bleed / unstable post resuscitation
If fails, may need emergency surgery Moderate bleeds
IP OGD within 24hrs Minor bleeds / unproven
Consider OP OGD
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Mallory Weiss tear
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Mallory Weiss tear
Hx Vomiting (++) prior to haematemesis Often associated with alcohol Small volume blood “streaks”, mixed with vomit
Ex Normal examination
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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
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Anal Fissure
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Haemorrhoids
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Fistula in aino
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Moderate & Sever Bleeds
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Resuscitation
Airway Breathing Circulation Disability Exposure
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Airway & Breathing
Large clots can block the airway May have reduced conscious level
(shock/encephalopathy) At risk of aspiration due to vomiting Give 15l/min oxygen via face mask
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Circulation – recognising shocked patients
Pale Clammy skin High Cap Refill (>2s) Weak pulse Tachycardia (NB beta blockers) Hypotention (High resp rate) (Confusion)
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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 (see also massive haemorrage protocol)
IV fluids to maintain BP>100 systolic Start with up to 2l N Saline Stat Then progress to blood
IV FFP if variceal bleed suspected or INR>1.3 Urinary catheter
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Blood
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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
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Massive Haemorrhage Protocol
Purpose: to improve and streamline blood administration to those
with massive blood loss
Massive Hemorrhage protocol kicks in in the following circumstances: 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
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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
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Prescribing exercise
Jo Blogs (dob 01/01/1955, hospital no X111000) is in Resus unstable with a massive upper GI bleed (probably variceal)
Please prescribe him: 2 units of blood IV Tazocin IV Terlipressin
Hand in your prescriptions at the coffee break (with your name on) to be checked
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Questions & Coffee Break
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Why do we do investigations in patients with GI bleeds?
Take a minute to brainstorm for reasons for investigating patients with GI bleeds
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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
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Investigations - Types
Bedside Blood tests Imaging Endoscopy Surgery
Further details of all of these in Appendix at end
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Case Studies – Group Work
Groups of 4-5, same colour cases For Case 2, list and justify:
Diagnosis & 3 main differentials Severity of Bleed Rockall Score (pre endoscopy) if appropriate Investigations & Management
Make flip chart Present case afterwards Clinical Guidelines available if desired 5-10 minutes
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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
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Case Red 2 Diagnosis
Diverticular bleed Severity
moderate (neither mild nor severe) 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
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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
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Treatment of underlying disease
Eg definitive treatment of Cancers Ulcers Diverticular disease .....
Conservative, Medical or Surgical Urgent or Elective
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Diverticular Disease
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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
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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
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Ulcerative Colitis
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Crohn’s Disease
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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
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Case Yellow 2 Diagnosis
Ischemic colitis Severity
Severe Rockall Score
n/a Ix and Mx
ABCDE resuscitation ECG, Rigid sigi, Bloods (Hb, Trop I, U&Es,
inflammatory markers), CT abdo, Colonoscopy NBM, IVI, Antibiotics, +/- Surgery
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Ischemic Colitis
Hx AF / IHD Generalised pain Colitic symptoms Very unwell
Ex “pain out of proportion with signs” No localised signs (until perforation) Acidosis
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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
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Case Blue 2
Diagnosis Bleeding Varacies
Severity Severe
Rockall Score Age 0, Shock 2, Co-morbidity 3 = Total 5
Ix and Mx ABCDE resucitation, inc up to 2l fluids, FFP, ? blood Terlipressin, Tazocin, ?Vitamin K, Urgent senior r/v,
urgent endoscopy
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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
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Case Blue 2
OGD Results Large oesophageal varices, no active bleeding.
Clots in stomach. Varices banded. Post endoscopy Rockall Score
Diagnosis 1, SRH 2 Total 8 Outcome
High risk of death, needs close monitoring (e.g. HDU / ITU)
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Rockall Score (Upper GI only)Score
Post endoscopy 8
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
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Oesophagael Varices
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Varices
Hx Known liver disease Known varices High alcohol intake
Ex Stigmata of liver disease Smell of alcohol on breath
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Yellow sclera
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Caput Medusae
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Man with gynaecomastia
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Palmar erythema
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Dupuytren’s contracture
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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 epigastrium, no guarding, stomach slightly bloated, no
organomegaly PR – black, tarry motion, no red blood Other examination normal
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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 (exclude perf)
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Case Green 2
Results OGD after 2hrs (pt deteriorated) – Blood in
stomach ++, large duodenal ulcer, spurting blood Post endoscopy Rockall Score
Diagnosis 1, SRH 2, Total 5
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Rockall Score (Upper GI only)Score
Post endoscopy score 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
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Gastric and Duodenal Ulcers
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Gastritis
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Peptic ulcers and Erosions
Hx Associated with typical pain NSAID use Previous gastritis / ulcers Stress (including operations)
Ex Epigastric tenderness / guarding
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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
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Post op Complications
Rare ++++++ Must be considered if recent intervention More commonly, re-bleeds post haemostaic
interventions Can be very large bleeds, clots+++
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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
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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)
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ECG
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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 Abdomen - Vague Mass RIF, non tender PR – soft brown stool on examining finger.
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Case 3 Diagnosis
Angina caused by anaemia, secondary to cecal carcinoma
Severity Bleed is not acute but chronic, so n/a
Ix and Mx Treat angina (GTN spray), consider ACS Slow transfusion, +/- diuretic, as at risk of overload
(not acute blood loss, plus cardiac symptoms) CT scan +/- colonoscopy to confirm diagnosis Definitive treatment for cancer (Right Hemicolectomy)
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Colon Cancer
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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
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Gastric Cancer
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Oesophageal cancer
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Features of Upper GI cancers
1 minute, work in pairs Discuss features of history and examination
that suggest upper GI malignancy as cause for bleed
List 3 features on history 3 findings on examination
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Oesophageal & Gastric Malignancies
Hx Weight loss, loss of appetite, general lethargy Dysphagia Known malignancy Recent stent insertion
Ex Emaciated Palpable craggy liver edge Palpable neck LN (rare) Visible mets (rare)
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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
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Summary (2)
Likely diagnosis from history and examination Working diagnosis to guide management Use guidelines / pathways to aid
management ASK FOR HELP when needed!!!
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ANY QUESTIONS?
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Appendix – Investigations for GI bleed patients
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Bedside
Fecal Ocult 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
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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
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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
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Laing C J et al. Radiographics 2007;27:1055-1070
©2007 by Radiological Society of North America
CT Angiogram
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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 (Chron’s)
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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
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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
Flexi Sig and Colon – not in bleeding patients Poor vision – risk of perforation
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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