GI HAEMORRHAGE D Bondin - eastlancsdue.nhs.uk HAEMORRHAGE D Bondin.pdf · GI HAEMORRHAGE D Bondin Author: DuffyL Created Date: 5/17/2010 9:16:04 AM

GI HAEMORRHAGEGI HAEMORRHAGE

44THTH FEBRUARY 2010FEBRUARY 2010

DR. DANIELA BONDINDR. DANIELA BONDIN

CONTENTSCONTENTS

�� CASE ONECASE ONE

�� CASE TWOCASE TWO

�� LEARNING POINTSLEARNING POINTS

�� QUESTIONSQUESTIONS

WHAT WOULD YOU DO?WHAT WOULD YOU DO?

�� You have started your nights onYou have started your nights on--call call

during your surgical placement and have during your surgical placement and have

been bleeped to review a patient who has been bleeped to review a patient who has

passed blood on defecation.passed blood on defecation.

�� What would you like to know over the What would you like to know over the

phone? Would you like the nurse to do phone? Would you like the nurse to do

anything?anything?

CASE ONECASE ONE-- Mrs GreenMrs Green

�� The nurse tells you that the patient is a 70 The nurse tells you that the patient is a 70

year old lady, Mrs Green who has been year old lady, Mrs Green who has been

recently admitted under Mr. Scott for an recently admitted under Mr. Scott for an

elective operation (but unsure of the elective operation (but unsure of the

name of the operation). She has a blood name of the operation). She has a blood

pressure of 100/60, pulse 95, Temp: 37.1, pressure of 100/60, pulse 95, Temp: 37.1,

SatsSats 94% on Air94% on Air

CASE ONE CASE ONE –– Mrs GreenMrs Green

�� You have reached the You have reached the

ward. Leafing through the ward. Leafing through the

prepre--op notes, Mrs Green is op notes, Mrs Green is

due for an OGD and a due for an OGD and a

sigmoidoscopysigmoidoscopy tomorrow tomorrow

for changes in bowel for changes in bowel

habits.habits.

�� You are now going to You are now going to

review the patient. What review the patient. What

will you do?will you do?


�� Take a historyTake a history

�� Examine the patientExamine the patient

�� Organise investigationsOrganise investigations

�� Further managementFurther management

CASE ONECASE ONE-- Mrs GREENMrs GREEN

�� TAKE A HISTORYTAKE A HISTORY

1.1. Name/AgeName/Age

2.2. Ask the patient why she in hospitalAsk the patient why she in hospital

3.3. Previous episodes of bleedingPrevious episodes of bleeding

4.4. Changes in bowel habits including Changes in bowel habits including tenesmustenesmus, , melenamelena, , haematocheziahaematochezia, unexplained fever, jaundice, unexplained fever, jaundice

5.5. Blood transfusions in the pastBlood transfusions in the past

6.6. Known to be anaemicKnown to be anaemic

7.7. Regarding acute episode in hospital: how much blood was Regarding acute episode in hospital: how much blood was passed, fresh/mixed with stool or on tissue paper, associated wipassed, fresh/mixed with stool or on tissue paper, associated with th straining/recent constipation, associated with pain, does the straining/recent constipation, associated with pain, does the patient feel faint/unwellpatient feel faint/unwell

8.8. Drug history: patient on aspirin, Drug history: patient on aspirin, clopidogrelclopidogrel, , warfarinwarfarin, NSAIDS, NSAIDS


�� EXAMINE THE PATIENTEXAMINE THE PATIENT

1.1. ABCDABCD

2.2. Assess patients hydration status: Pulse, Assess patients hydration status: Pulse, BP, Mucous membranes, Urine outputBP, Mucous membranes, Urine output

3.3. DRE!! IS MANDATORYDRE!! IS MANDATORY

IF YOU DON’T PUT YOUR FINGER INTO IT, IF YOU DON’T PUT YOUR FINGER INTO IT,

YOU’LL PUT YOUR FOOT INTO IT!YOU’LL PUT YOUR FOOT INTO IT!


�� ORGANISE INVESTIGATIONSORGANISE INVESTIGATIONS

1.1. Bloods: FBC, Bloods: FBC, U&EsU&Es, , CoagCoag, Group and , Group and

savesave

2.2. ECG: ECG: Sudden loss of blood can lead to chest pain and heart Sudden loss of blood can lead to chest pain and heart

failurefailure

3.3. +/+/-- Blood transfusionBlood transfusion


�� FURTHER MANAGEMENTFURTHER MANAGEMENT

1.1. Fluid resuscitationFluid resuscitation-- GelafusionGelafusion

2.2. Chase blood resultsChase blood results

3.3. Blood Transfusion Blood Transfusion HbHb <7/9 +/<7/9 +/-- FFPsFFPs

4.4. ReRe--asses patients observationsasses patients observations

5.5. Input and output charts including observation of stool Input and output charts including observation of stool samplessamples

6.6. Inform your seniorInform your senior-- Your registrar may want to Your registrar may want to perform an urgent perform an urgent SigmoidoscopySigmoidoscopy/surgery even in the /surgery even in the middle of the nightmiddle of the night

7.7. ReRe--visit the patient throughout the nightvisit the patient throughout the night

8.8. Inform the day teamInform the day team


�� What is your differential diagnosis?What is your differential diagnosis?

1.1. DiverticularDiverticular diseasedisease

2.2. AngiodysplasiaAngiodysplasia

3.3. HaemorrhoidsHaemorrhoids

4.4. Colorectal carcinomaColorectal carcinoma

5.5. Inflammatory bowel diseaseInflammatory bowel disease

6.6. Infective/Infective/ischaemicischaemic colitiscolitis

Thank you for looking Thank you for looking

after Mrs Green!after Mrs Green!

CASE TWO CASE TWO –– Mr SmithMr Smith

Your on your first surgical night shift and Your on your first surgical night shift and

your Registrar phones you to go down to your Registrar phones you to go down to

A&E as both the SHO and himself are stuck A&E as both the SHO and himself are stuck

in theatre performing a major operation.in theatre performing a major operation.

Your in A&E which is swarming with patients. A Your in A&E which is swarming with patients. A

fight broke out during the fight broke out during the ManchsterManchster United and United and

Blackburn football game and there are injured fansBlackburn football game and there are injured fans

everywhere. A nurse rushing by tells you to look ateverywhere. A nurse rushing by tells you to look at

the gentleman in cubicle 3.the gentleman in cubicle 3.


��What are you What are you

going to do?going to do?


�� Finding the patients notes you note that Finding the patients notes you note that the patient has come to A&E with one the patient has come to A&E with one episode of ? Vomiting ? Coughing up fresh episode of ? Vomiting ? Coughing up fresh bloodblood

�� An An auxillaryauxillary nurse doing the patients nurse doing the patients observations rushes out of cubicle three observations rushes out of cubicle three telling you ‘ The patient isn’t looking telling you ‘ The patient isn’t looking great’!great’!


�� The patient appears drowsy but easily The patient appears drowsy but easily

rousablerousable and he appears very pale.and he appears very pale.

�� WHAT DO YOU DO NOW, WHAT DO YOU WHAT DO YOU DO NOW, WHAT DO YOU

THINK THE PATIENT MAY HAVE?THINK THE PATIENT MAY HAVE?


�� CALL FOR HELP! FIND ANYONE WHO CAN CALL FOR HELP! FIND ANYONE WHO CAN

GIVE YOU A HAND!GIVE YOU A HAND!

�� THINK: The patient is drowsy but alive. If your THINK: The patient is drowsy but alive. If your

suspecting an Upper GI bleed take a brief suspecting an Upper GI bleed take a brief

history first looking out for:history first looking out for:

1.1. Fresh blood? How much blood? Coughing or Fresh blood? How much blood? Coughing or

vomiting? Previous history of similar event?vomiting? Previous history of similar event?

2.2. Alcohol intake? Regular meds: aspirin, Alcohol intake? Regular meds: aspirin,

clopidogrelclopidogrel, NDAIDS, NDAIDS


�� Mr Smith tells you that his vomiting about Mr Smith tells you that his vomiting about

a pint of fresh blood. His drinks a pint of fresh blood. His drinks onlyonly 2020--

40 cans of beer everyday and is not on 40 cans of beer everyday and is not on

any medication. His abdomen is tender.any medication. His abdomen is tender.

�� As you are taking a history Mr. Smith As you are taking a history Mr. Smith

vomits another pint of blood in front of vomits another pint of blood in front of

you.you.

�� WHAT ARE YOU GOING TO DO NOW?WHAT ARE YOU GOING TO DO NOW?


�� CALL YOUR SENIORSCALL YOUR SENIORS

�� ABCDABCD

1.1. AIRWAYAIRWAY-- suck out any suck out any vomitusvomitus from patients mouth, from patients mouth, put on an oxygen maskput on an oxygen mask

2.2. BREATHING BREATHING –– listen to the patients chest listen to the patients chest

3.3. CIRCULATION CIRCULATION -- put in two large bore put in two large bore cannulaecannulae, take , take bloods including a group and save, bloods including a group and save, HbHb, , LFTsLFTs, , U&EsU&Es, , CoagCoag, give stat doses of , give stat doses of gelafusiongelafusion and ask for regular and ask for regular observationsobservations

4.4. DISSABILITYDISSABILITY-- assess patients GCS, feel the patients assess patients GCS, feel the patients abdomen, is he abdomen, is he peritoniticperitonitic? ?


�� FURTHER MANAGEMENTFURTHER MANAGEMENT

1.1. Insertion of Insertion of SengstakenSengstaken--BlackmoreBlackmore tubetube

2.2. Beta blockerBeta blocker

3.3. GTNGTN

4.4. EndoscopyEndoscopy for for sclerotherapysclerotherapy/banding/banding


�� Your registrar takes Mr. Smith to theatre and Your registrar takes Mr. Smith to theatre and together with the ontogether with the on--call consultant call consultant endsocopicendsocopicslerotherapyslerotherapy is performed.is performed.

�� 90% of patients with portal hypertension have 90% of patients with portal hypertension have varicesvarices

�� 30% of patients with 30% of patients with varicesvarices will have an upper gastrointestinal will have an upper gastrointestinal bleedbleed

�� 80% of GI bleed in patients with portal hypertension comes from 80% of GI bleed in patients with portal hypertension comes from varicesvarices

�� The mortality of a The mortality of a varicealvariceal bleed is approximately 50%bleed is approximately 50%

�� 70% of patients will re70% of patients will re--bleedbleed

�� Survival is dependent on the degree of hepatic impairmentSurvival is dependent on the degree of hepatic impairment

Causes of Upper gastrointestinal Causes of Upper gastrointestinal

bleedbleed

1.1. Peptic ulcer (50%)Peptic ulcer (50%)

2.2. Gastric erosionsGastric erosions

3.3. Oesophageal or gastric Oesophageal or gastric varicesvarices

4.4. Mallory Mallory –– Weiss tearWeiss tear

5.5. AngiodysplasiaAngiodysplasia

6.6. Gastric Gastric NeoplasmNeoplasm

LEARNING POINTSLEARNING POINTS

�� HOW TO MANAGE UPPER GI HAEMORRHAGEHOW TO MANAGE UPPER GI HAEMORRHAGE

�� HOW TO MANAGE LOWER GI HAEMORRHAGEHOW TO MANAGE LOWER GI HAEMORRHAGE

�� REMEMBER HISTORY, EXAMINATIONREMEMBER HISTORY, EXAMINATION--ABCD, ABCD,

INVESTIGATIONS, MANAGEMENTINVESTIGATIONS, MANAGEMENT

�� ALWAYS LET YOUR SENIORS KNOWALWAYS LET YOUR SENIORS KNOW

ANY QUESTIONS?ANY QUESTIONS?

THANK YOUTHANK YOU

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GI HAEMORRHAGE D Bondin - eastlancsdue.nhs.uk HAEMORRHAGE D Bondin.pdf · GI HAEMORRHAGE D Bondin Author: DuffyL Created Date: 5/17/2010 9:16:04 AM