Transcript Gastrointestinal Haemorrhage

Gastrointestinal
Haemorrhage
Pre Lecture Handout
Acute Block Objectives
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GI Bleeds
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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
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Knowledge
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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
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Appreciate knowing purpose of investigations allows correct
choice of investigation
Outline
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Recognising GI Bleeds
Causes of GI Bleeds
Features of specific Lower GI Bleeds
Investigation of Lower GI Bleeds
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Upper GI Bleeds in Case studies in week 5
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What’s blood?
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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
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List different colours blood may be in vomit or
stool
Why does blood change
colour?
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Stomach – Acid
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Small Bowel – Digestive enzymes
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Bright Red -> brown / coffee grounds
Bright Red -> Dark Red
Colon – Bacteria
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Bright Red-> Dark Red -> Black
PR Bleeds (haematochezia)
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Black – Cecum or Upper GI
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Dark Red – Transverse colon, Cecum
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Melaena, Tar like, smelly
Or Upper GI, large volume
Loose / soft stools
mixed with stools
Bright Red – Anus, Rectum, Sigmoid
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Mixed with stools - sigmoid / descending
Coating stools / on paper – rectal / anal
Rarely massive upper GI bleed
Consider occult GI blood loss
when:
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Unexplained anaemia
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Sudden episode of hypotension and
tachycardia, easily corrected
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Low volume chronic bleeds, eg Gastric Ca,
Cecal Ca
Acute upper GI bleed
melaena follows hours later
History of bleeds / risk factors, shocked pt
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Symptoms missed, or appear later
Causes of GI Bleed
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Brainstorm all causes of GI bleeds
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Groups, 2-4 people
2 minutes
Make 2 lists, most common to least common
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Divide into upper & lower GI causes
1minute
Case 1
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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
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Hx
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Prone to constipation
Loose motion, then blood mixed in, then only
blood
Often out of the blue
Known diverticular disease
Ex
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Abdomen usually non tender
Blood PR, no masses, no anorectal pathology
Inflammatory Bowel Disease
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Hx
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Known IBD
Loose motions, up to 20x/day
Now mucus and blood, increased frequency
Ex
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Thin
Tender abdomen
Systemic signs of IBD
Case 2
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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
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Hx
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AF / IHD
Generalised pain
Colitic symptoms
Very unwell
Ex
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“pain out of proportion with signs”
No localised signs (until perforation)
Acidosis
Benign Anorectal
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Haemorrhoids
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Feel “lump”, Itch
Anal Fissure
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Bright red blood on toilet paper, not mixed with
stools
Diagnosed by typical PR appearances
Anal pain +++ with motions
Fistula in aino
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Soiling on underwear, recurrent abscesses
Case 3
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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
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Hx
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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
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Palpable mass (abdominal / PR)
Visible weight loss
Craggy liver edge
May be normal
Management
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Resuscitation
Investigations to confirm cause of bleed
Specific treatment of cause
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Investigations may be IP or OP
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Resuscitation
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Airway
Breathing
Circulation
Disability
Exposure
Circulation – recognising
shocked patients
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Pale
Clammy skin
High Cap Refill (>2s)
Weak pulse
Tachycardia (NB beta blockers)
Hypotention
(High resp rate)
(Confusion)
Circulation - Interventions
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2 large bore IV cannulae (14 or 16 G)
Send blood for FBC, clotting, G&S or Xmatch, if bleeding is severe inform blood
bank
Fluid challenge, if shocked 2L warmed
crystalloid
If continued shock: blood, clotting factors
Urinary catheter
Blood
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O Negative
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Type specific (red label ...)
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20 mins
transient response, ongoing bleed
Fully X matched
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immediately
shock not responding to IV fluids
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
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Severe bleeds
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Moderate bleeds
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Resuscitation
IP investigation +/- treatment
IP observation till bleed stops
Often OP investigation +/- treatment
Mild / low risk bleeds
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Early discharge
OP investigation +/- treatment
Severe Bleeds
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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)
Low risk patients
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Consider for discharge or non-admission with
outpatient follow-up if:
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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
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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
Investigations - Types
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Bedside
Blood tests
Imaging
Endoscopy
Surgery
Treatment
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Haemostasis
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Most stop spontaneously +/- medical managment
Angiogram Embolisation
Occasionally surgery
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Generalised colonic bleeds (eg colitis)
Endoscopy rarely
Treatment of underlying disease
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Medical or Surgical
Urgent or Elecitve
Summary
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Colour of blood important for location of bleed
ABCDE resuscitation
Likely diagnosis from history and examination
Targeted investigations
Allows
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Planning of treatment
Priorities