Mohammad Mobasheri

SpR General Surgery

Maybe classified into:
Upper GI bleeding (proximal to DJ flexure)
Variceal bleeding
Non-variceal bleeding
Lower GI bleeding (distal to DJ flexure)

Upper GI bleeding 4x more common than

lower GI bleeding

Emergency resuscitation same for upper and

lower GI bleeds
Takes priority over determining the diagnosis/cause
ABC (main focus is C)
Oxygen: 15L Non-rebreath mask
2 large bore cannulae into both ante-cubital fossae
Take bloods at same time for FBC, U&E, LFT, Clotting, X match 6Units
Catheterise
IVF initially then blood as soon as available (depending on
urgency: O-, Group specific, fully X-matched)
Monitor response to resuscitation frequently (HR, BP, urine output,
level of consciousness, peripheral temperature, CRT)
Stop anti-coagulants and correct any clotting derrangement
NG tube and aspiration (will help differentiate upper from lower GI
bleed)
Organise definitive treatment (endoscopic/radiological/surgical)
 RR, HR, and BP can be used to estimate
degree of blood loss/hypovolaemia
Class I Class II Class III Class IV
Volume Loss 0-750 750-1500 1500-2000 >2000
(ml)
Loss (%) 0-15 15-30 30-40 >40
RR 14-20 20-30 30-40 >40
HR <100 >100 >120 >140
BP Unchanged Unchanged Reduced Reduced
Urine >30 20-30 5-15 Anuric
Output
(ml/hr)
Mental Restless Anxious Anxious/con Confused/
State fused lethargic
 Aim of history and examination is 3 fold
1. Identify likely source upper vs lower and
potential cause
2. Determine severity of bleeding
3. Identify precipitants (e.g. Drugs)
 PC/HPC
Duration, frequency, and volume of bleeding (indicate severity of bleeding)
Nature of bleeding: will point to source
Haematemesis (fresh or coffee ground)/melaena suggest upper GI bleed. (Note a very brisk upper GI bleed can present with
dark or bright red blood PR).
PR Dark red blood suggests colon
PR Bright red blood suggests rectum, anus
If PR bleeding, is blood being passed alone or with bowel opening (if alone suggests heavier bleeding)
If with bowel opening is blood mixed with the stool (colonic), coating the stool (colonic/rectal), in the toilet water (anal), on
wiping (anal)
Ask about associated upper or lower GI symptoms that may point to underlying cause
E.g. Upper abdominal pain/dyspeptic symptoms suggest upper GI cause such as peptic ulcer
E.g. 2. lower abdo pain, bowel symptoms such as diarrhoea or a background of change in bowel habit suggest lower GI
cause e.g. Colitis, cancer
Previous episodes of bleeding and cause
PMH
History of any diseases that can result in GI bleeding, e.g. Peptic ulcer disease, diverticular disease, liver disease/cirrhosis
Bleeding disorders e.g. haemophilia
DH
Anti-platelets or anti-coagulants can exacerbate bleeding
NSAIDs and steroids may point to PUD
SH
Alcoholics at risk of liver disease and possible variceal bleeding as a result
Smokers at risk of peptic ulcer disease
 Reduced level of consiousness
Pale and clammy
Cool peripheries
Reduced CRT
Tachcardic and thready pulse
Hypotensive with narrow pulse pressure
Tenderness on abdominal examination may point to
underlying cause e.g. Epigastric peptic ulcer
Stigmata of chronic liver disease (palmer erythema,
leukonychia, dupuytrens contracture, liver flap, jaundice,
spider naevi, gynacomastia, shifting dullness/ascites)
Digital rectal examination may reveal melaena, dark red
blood, bright red blood
 Upper GI bleeding refers to bleeding from
oesophagus, stomach, duodenum (i.e.
Proximal to ligmanet of treitz)

Bleeding from jejunum/ileum is not common

 Acute Upper GI bleeding presents as:
Haematemesis (vomiting of fresh blood)
Coffee ground vomit (partially digested blood)
Melaena (black tarry stools PR)

If bleeding very brisk and severe then can

present with red blood PR!
If bleeding very slow and occult then can
present with iron deficiency anaemia
Cause of Bleeding Relative Frequency
Peptic Ulcer 44
Oesophagitis 28
Gastritis/erosions 26
Duodenitis 15
Varices 13
Portal hypertensive 7
gastropathy
Malignancy 5
Mallory Weiss tear 5
Vascular Malformation 3
Other (e.g. Aortoenteric rare
fistula)
 Identifies patients at risk of adverse
outcome following acute upper GI bleed
Variable Score 0 Score 1 Score 2 Score 3

Age <60 60-79 >80 -

Shock Nil HR >100 SBP <100 -

Co-morbidity Nil major - IHD/CCF/major Renal

morbidity failure/liver
failure
Diagnosis Mallory Weiss All other GI malignancy -
tear diagnoses
Endoscopic None - Blood, adherent -
Findings clot, spurting
vessel

Score <3 carries good prognosis

Score >8 carries high risk of mortality
 Emergency resuscitation as already described

Endoscopy
Urgent OGD (within 24hrs) diagnostic and therepeutic
Treatment administered if active bleeding, visible vessel, adherent blood clot
Treatment options include injection (adrenaline), coagulation, clipping
If re-bleeds then arrange urgent repeat OGD

Pharmacology
PPI (infusion) pH >6 stabilises clots and reduces risk of re-bleeding
following endoscopic haemostasis
Tranexamic acid (anti-fibrinolytic) maybe of benefit (more studies
needed)
If H pylori positive then for eradication therapy
Stop NSAIDs/aspirin/clopidogrel/warfarin/steroids if safe to do so
(risk:benefit analysis)
 Surgery
Reserved for patients with failed medical
management (ongoing bleeding despite 2x OGD)
Nature of operation depends on cause of bleeding
(most commonly performed in context of bleeding
peptic ulcer: DU>GU)
E.g. Under-running of ulcer (bleeding DU), wedge
excision of bleeding lesion (e.g. GU), partial/total
gastrectomy (malignancy)
 Suspect if upper GI bleed in patient with history of chronic
liver disease/cirrhosis or stigmata on clinical examination
Liver Cirrhosis results in portal hypertension and
development of porto-systemic anastamosis (opening or
dilatation of pre-existing vascular channels connecting
portal and systemic circulations)
Sites of porto-systemic anastamosis include:
Oesophagus (P= eosophageal branch of L gastric v, S= oesophageal branch of
azygous v)
Umbilicus (P= para-umbilical v, S= infeior epigastric v)
Retroperitoneal (P= right/middle/left colic v, S= renal/supra-renal/gonadal v)
Rectal (P= superior rectal v, S= middle/inferior rectal v)
Furthermore, clotting derrangement in those with chronic
liver disease can worsen bleeding
 Emergency resuscitation as already described
Drugs
Somatostatin/octreotide vasoconstricts splanchnic circulation and reduces pressure in portal system
Terlipressin vasoconstricts splanchnic circulation and reduces pressure in portal system
Propanolol used only in context of primary prevention (in those found to have varices to reduce risk
of first bleed)
Endoscopy
Band ligation
Injection sclerotherapy
Balloon tamponade sengstaken-blakemore tube
Rarely used now and usually only as temporary measure if failed endoscopic management
Radiological procedure used if failed medical/endoscopic Mx
Selective catheterisation and embolisation of vessels feeding the varices
TIPSS procedure: transjugular intrahepatic porto-systemic shunt
shunt between hepatic vein and portal vein branch to reduce portal pressure and bleeding from varices): performed if
failed medical and endoscopic management
Can worsen hepatic encephalopathy

Surgical
Surgical porto-systemic shunts (often spleno-renal)
Liver transplantation (patients often given TIPP/surgical shunt whilst awaiting this)
 TIPSS

Sengstaken-Blakemore Tube
Surgical porto-systemic shunt (spleno-renal shunt)
 Prognosis closely related to severity of underlying chronic
liver disease (Childs-Pugh grading)
Child-Pugh classification grades severity of liver disease into
A,B,C based on degree of ascites, encephalopathy, bilirubin,
albumin, INR

Mortality 32% Childs A, 46% Childs B, 79% Childs C

 Lower GI bleed refers to bleeding arising
distal to the ligament of Treitz (DJ flexure)

Although this includes jejunum and ileum

bleeding from these sites is rare (<5%)

Vast majority of lower GI bleeding arises

from colon/rectum/anus
 Lower GI bleeding presents as:
Dark red blood PR more proximal bleeding point (e.g. Distal
small bowel, colon)
Bright red blood PR more distal bleeding point (e.g. rectum,
anus)
PR blood maybe:
mixed or separate from the stool
If separate from the stool it maybe noticed in the toilet water or on wiping
Passed with motion or alone

If blood mixed with stool (as oppose to separate from

it) suggests more proximal bleeding
If bleeding very slow and occult then can present with
iron deficiency anaemia
Colon Rectum Anus
Diverticular Disease Polyps Haemorrhoids
Polyps Malignancy Fissure
Malignancy Proctitis Malignancy
Colitis
Angiodysplasia
 Emergency resuscitation as already described

Pharmacological
Stop NSAIDS/anti-platelets/anti-coagulants if safe
Tranexamic acid

Endoscopic
OGD (15% of patients with severe acute PR bleeding will have an
upper GI source!)
Colonoscopy diagnostic and therepeutic (injection, diathermy,
clipping)
 Radiological
CT angiogram diagnostic only (non-invasive)
Determines site and cause of bleeding

Mesenteric Angiogram diagnostic and therepeutic

(but invasive)
Determines site of bleeding and allows embolisation of
bleeding vessel
Can result in colonic ischaemia

Nuclear Scintigraphy technetium labelled red blood

cells: diagnostic only
Determines site of bleeding only (not cause)
 Surgical Last resort in management as
very difficult to determine bleeding point at
laparotomy
Segmental colectomy where site of bleeding is
known
Subtotal colectomy where site of bleeding unclear
Beware of small bowel bleeding always
embarassing when bleeding continues after large
bowel removed!
 Resuscitate

OGD (to exclude upper GI cause for severe PR bleeding)

Colonoscopy (to identify site and cause of bleeding and

to treat bleeding by injection/diathermy/clipping)
often unsuccesful as blood obscures views

CT angiogram (to identify Mesenteric angiogram (to identify

site and cause of site of bleeding and treat
bleeding) bleeding by embolisation of
vessel)

Surgery
 As 85% of lower GI bleeds will settle
spontaneously the interventions mentioned
on previous slide are reserved for:
Severe/Life threatening bleeds

In the 85% where bleeding settles

spontaneously OPD investigation is required
to determine underlying cause:
Endoscopy: flexible sigmoidoscopy, colonoscopy
Barium enema
 Insufficient iron in the body for
haemopoeisis

Decrease Hb and MCV

Decreased serum iron and Ferritin
Increased TIBC and serum transferrin
 Increased Iron demand
Chronic Blood loss
Think Chronic bleeding (often occult) from GI tract in men and post-menopausal
females (pre-menopause menorrhagia most common cause) e.g. Colonic polyp or
cancer, gastric/duodenal ulcer or malignancy
Chronic haemolysis
Pregnancy

Insufficient Iron intake

Diet lacking in iron
Vegans plant based iron poorly absorbed compared to meat based iron

Malabsorption of iron
Small intestinal disease e.g. Crohns, caeliac disease
Lack of vitamin C (important for iron absorption)
 In adults >50yrs of age the most common
cause of Iron deficiency anaemia is chronic
occult GI bleeding
In females <50yrs most common cause is blood
loss during menses with inadequate replacement

In developing world intestinal parasitic infection

causing chronic blood loss from the GI tract is the
most common cause of iron deficiency anaemia
(rare in developed world)
 To confirm iron deficiency anaemia
Hb, MCV, Ferritin, transferrin, TIBC
Rarely bone marrow aspirate (gold standard but invasive:
rarely performed)

OGD and colonoscopy

Perform in males and post-menopausal females
In pre-menopausal females menorrhagia is most common
cause and often OGD/colonoscopy not required unless
other symptoms warrant it (e.g. dyspepsia, dysphagia, PR
bleeding, change in bowel habit, family history etc.)
Note that iron deficiency anaemia maybe the only sign of
an occult GI malignancy
Questions