GI & Hepatology JC056: Coffee Ground Vomitus / Tarry Stool: Upper GI Bleeding

Question 1

Upper GI bleeding definition

Answer 1

Bleeding from a source proximal to ***ligament of Treitz (at Duodeno-Jejunal flexure)

Ligament of Treitz:
- connect Duodeno-Jejunal flexure to Connective tissue surrounding SMA + Celiac artery

Question 2

Definition of other terms

Answer 2

Small bowel bleeding:
- any bleeding distal to **Ampulla of Vater + proximal to **Ileocecal valve

Overt GI bleeding:
- passage of visible blood (including haematemesis, coffee ground vomiting, melena, haematochezia)

Occult GI bleeding:
- GBI with blood not detected by naked eye
- notice possibility of bleeding ∵ **Fe deficiency anaemia (FDA) / **Positive faecal occult blood test

Obscure GI bleeding:
- ***source of bleeding (either Overt / Occult) remains unknown despite
—> OGD + CLN (colonoscopy) +/- SB radiographic evaluation (traditional definition)
—> OGD + CLN + SB workup (radiographic testing, videocapsule endoscopy, enteroscopy) (stricter definition) (all need to be negative before conclude obscure GIB)

Question 3

***Presentation of UGIB

Answer 3

Depends on **Volume + **Location of bleeding:

Small to Moderate amount (usually more Chronic course):
1. Symptoms of anaemia (fatigue, palpitation, dyspnea, dizziness, postural hypotension)
2. Asymptomatic (only incidental findings of Fe deficiency anaemia / +ve Faecal occult blood)

Larger amount (usually more Acute course):
1. Haematemesis (fresh blood / coffee-ground emesis (bleeding less severe / active: enough time for gastric acid to act on heme —> brownish))
2. Fresh blood / Coffee-ground aspirate from NG tube
3. Melena
4. Haematochezia (bright red / maroon blood: rare in UGIB unless high volume + rapid transit time)

Question 4

Melena

Answer 4

• Black tarry stool
• Other characteristics: loose, sticky, malodourous
• Fresh (some fresh blood component suggesting **ongoing bleeding) vs Old (suggestive of **cessation of ongoing bleeding)
• Black colour: Heme oxidised by intestinal bacteria —> ***Hematin
• Usually a ***cathartic (∵ blood component stimulates gut motility) —> patients describe loose stool / diarrhoea

DDx of black stool:
1. **Fe intake (greenish / black colour)
2. **Bismuth (reddish black)
3. Beetroot (reddish black)
4. Activated charcoal

Question 5

***Proximal vs Distal bleeding

Answer 5

Almost certain UGIB
- **Haematemesis
- **Blood in NG tube

NG tube clean:
- usually ***lower down, but can still be duodenal bleeding with competent pylorus preventing reflux of blood from duodenum into stomach

Melena:
- **Upper GI tract down to **Right / Proximal colon (enough time for bacteria to act on heme to hematin)

Haematochezia:
- ***Lower GI tract (but can still be massive bleeding from upper GI tract)

Question 6

Approach to patients with suspected UGIB

Answer 6

1. Assess severity of hypovolaemia
   - mild - moderate (<15% blood volume lost): Resting tachycardia
   - >=15%: Orthostatic hypotension (↓ SBP >20mmHg / ***↑ HR 20 from recumbent to standing)
   - >=40%: Supine hypotension
2. Resuscitation
   - **ABC —> secure airway if massive haematemesis with impaired consciousness
   - **Large bore IV cannula —> Fluid resuscitation + Packed cell transfusion
   - Monitor vital signs + ***urine output
   - ICU for severe, life-threatening cases (e.g. massive bleeding requiring inotropes / intubation)
3. History, P/E, Investigations
4. Treatment
   - Replace blood lost: Blood transfusion
   - Other measures
   - Upper endoscopy

Question 7

***History taking

Answer 7

記: Causes of bleeding: 潰瘍, 發炎, 嘔, 靜脈曲張, 腫瘤, 手術, 流血不止

1. Usual questions on onset, duration, frequency, episode etc.
2. Associated GI symptoms (provide hint on underlying cause):
   - **Epigastric pain: Peptic ulcer, Malignancy
   - **Vomiting e.g. after alcohol: Mallory-Weiss tear
   - **Acid reflux / heartburn: Esophagitis, Esophageal ulcer
   - **Painful dysphagia: Esophagitis, Esophageal ulcer
   - **Painless dysphagia: Malignancy
   - **Symptoms of cirrhosis (e.g. jaundice, leg edema, ascites): Variceal bleeding
   - ***Constitutional symptoms (LOW, LOA): Malignancy
   - Risk factors of DDx: H. pylori infection (treatment, follow-up test: need to confirm H. pylori eradication status), NSAIDs, HBV/HCV
3. Drug history / allergy
   - NSAIDs (patient may not know they are taking these drugs)
   —> ask IHD / chest pain, stroke, TIA, joint pain (e.g. OA, gout, recent sprain), dental extraction (from dentists)
   —> analgesic together with antacid
   —> given injections
   - Antiplatelets, Anticoagulants
   - Rate lower drugs: **β blockers, CCB —> **mask early signs of hypotension (i.e. tachycardia)
4. Past medical history
   - Peptic ulcer disease (higher risk of recurrence)
   - ***Radiation (suggest radiation enteritis)
5. GI surgical history
   - ***Anastomotic ulcer
6. Social history
   - Smoking (peptic ulcer disease)
   - Alcohol (alcohol gastritis, Mallory-Weiss tear after repeated severe vomiting)

Question 8

***Physical examination

Answer 8

1. ***Vital signs (TURBO-P)
2. Confirm the complaint
   - examine vomitus
   - examine material from NG tube
   - ***PR exam (to confirm whether real melena / Fe-stained stool, fresh / old melena, fresh per rectal bleeding)
3. General examination
   - **stigmata of chronic liver disease
   - skin + oral mucosa (hereditary diseases e.g. **Hereditary haemorrhagic telangiectasia, **Peutz-Jeghers syndrome (hyperpigmented macules: melanin spots, high tendency to develop cancer))
   - **cervical LN (malignancy)
4. Abdominal examination
   - **epigastric tenderness (rebound, guarding —> possibility of perforation)
   - abdominal mass (alcoholic cirrhosis)
   - **hepatosplenomegaly (cirrhosis)
   - ***PR exam
5. CVS exam
   - **aortic stenosis (associated with bleeding from **Angiodysplasia)
   - assess whether patient fit for endoscopy
6. Respiratory exam
   - assess whether patient fit for endoscopy

Question 9

***Investigations

Answer 9

1. CBC
   - ***Hb
   —> may not change in initial presentation ∵ loses both RBC + plasma
   —> may take a few hours for Hb to ↓ when interstitial fluid moves into vascular space / by IV infusion

• ***MCV
  —> normal usually in acute bleeding
  —> low in chronic Fe deficiency (small degree of chronic, intermittent, low volume bleeding), Thalassaemia
  —> high (from reticulocytosis)
• **Platelet
  —> normal
  —> **high (∵ reactive thrombocytosis to bleeding)
  —> ***low (∵ hypersplenism, consider variceal bleeding (if concomitant deranged LFT + prolonged INR))

2. **RFT
   - urea high in active / recent bleeding (∵ Hb is a protein —> ↑ urea when digested in GI tract)
   —> **urea abnormally higher than creatinine
3. LFT
   - cirrhosis —> variceal bleeding
4. Clotting profile
   - cirrhosis —> variceal bleeding
5. ***Type + screening, Cross matching
6. **CXR (erect)
   - rule out presence of free gas (upper endoscopy **CI if presence of perforation) (sensitivity 70-80%)
7. ECG
   - see if patient fit for urgent endoscopy
8. CT abdomen if suspected perforation (even if CXR does not show free gas)
   - if severe epigastric tenderness / rebound / guarding

Question 10

Prognostic scores of UGIB

Answer 10

• Predict adverse outcomes before endoscopy (e.g. further bleeding, death)
• Determine need of endoscopic intervention

1. ***Pre-endoscopic Rockall score
   - BP
   - pulse
   - age
   - comorbidities
2. ***Glasgow-Blatchford score (GBS) (>99% sensitivity)
   - BP
   - pulse
   - age
   - comorbidities
   - Hb, urea
   - laboratory tests
   - other markers e.g. melena, syncope

Question 11

Treatment: Blood transfusion

Answer 11

Restrictive strategy (Hb **<7 g/dL) vs Liberal strategy (Hb **<9 g/dL)

Restrictive strategy:
- Better survival at 6 weeks
- Better rebleeding rate (esp. cirrhosis) (∵ too much blood volume ↑ portal pressure —> rebleeding of esophageal varices)

Exception of Restrictive strategy:
1. **Haemodynamically unstable
2. **Underlying CVS disease (esp. ACS)
- transfusion threshold less certain
- level >= 8/9 g/dL is recommended —> to avoid triggering acute vascular events

Question 12

**Treatment: Other measures **before OGD

Answer 12

1. **FFP, **IV Vit K (if taking Warfarin) —> Correct coagulopathy + thrombocytopenia
   - keep INR <1.5
   - keep Plt >50
   - Use of FFP in cirrhosis is controversial (may ↑ portal pressure)
2. IV PPI in **active bleeding (for **peptic ulcer)
   - Esomeprazole **80mg bolus, then **8 mg/hour infusion
   - ↓ bleeding stigmata of peptic ulcer + ↓ need for endoscopic haemostatic intervention
3. Splanchnic vasoconstrictor (**if underlying cirrhosis)
   - **Terlipressin / Octreotide (in addition to PPI) —> ↓ portal pressure —> ↓ variceal bleeding
   - for known cirrhosis / suspected variceal bleeding e.g. known varices, S/S, lab results
4. Antibiotics (if underlying cirrhosis)
   - 3rd gen Cephalosporin (esp. advanced cirrhosis)
   - Quinolones
   —> ↓ risk of bacterial infection in cirrhosis patients with GI bleeding (lower / upper, variceal / non-variceal) —> ∵ GI bleeding lead to bacterial translocation —> ***Spontaneous bacterial peritonitis
   —> ↓ other infection risk e.g. pneumonia, UTI, skin infection etc.
5. +/- Prokinetics (if clinically severe / ongoing active UGIB —> ↓ chance of blood / clot retained in stomach which hinders endoscopic view)
   - IV Erythromycin
   - IV Metoclopramide

Question 13

Antibiotics in Cirrhosis with GIB

Answer 13

Advanced cirrhosis (Child-Pugh B / C):
- 3rd gen Cephalosporin (e.g. Ceftriaxone) (rather than Quinolone)

Question 14

Upper endoscopy

Answer 14

Rmb: NOT first thing to do in case of UGIB!!!

***After stabilisation
- within 24 hours if haemodynamically stable
- within 12 hours if haemodynamically unstable
- within 12 hours if suspected variceal bleeding

Inspect:
1. Esophagus
2. Stomach
3. Duodenum (up to level of Major duodenal papilla / Ampulla of Vater / 2nd part of Duodenum D2)
—> most pathologies located within these areas
—> looping of endoscopy in stomach —> scope may not be able to advance further beyond

Question 15

***Causes of Upper GI bleeding

Answer 15

***Common + Important (記: 潰瘍, 發炎, 嘔, 靜脈曲張, 腫瘤, 手術, 流血不止):
1. Ulcers / Erosions (duodenal, gastric, esophageal)
2. Gastritis, Duodenitis, Esophagitis
3. Gastroesophageal varices (uncommon but important)
4. Mallory-Weiss tear
5. Malignancy (gastric, esophageal)

Less common:
6. **Angiodysplasia / Telangiectasia
7. Anastomotic ulcer
8. Portal hypertensive gastropathy (only presents with occult GIB)
9. **Dieulafoy’s lesions
10. GIST with ulceration bleeding

Rare:
11. Aortoenteric fistula
12. Haemobilia, Haemosuccus pancreaticus
13. Crohn’s disease

Note:
Bleeding from Non-GI sources: ***Swallowed blood
- Epistaxis
- Haemoptysis
- Oral bleeding lesions

Question 16

1. Ulcers

Answer 16

• Duodenal, Gastric, Stomal ulcers
• 25-50% non-variceal UGIB
• ulcers high on **lesser curvature / in **postero-inferior wall of duodenal bulb (portion of duodenum closest to the stomach (5cm)) bleed more easily
  —> ∵ main vessels behind (e.g. left gastric artery, gastroduodenal artery)

Causes:
1. **H. pylori
2. **NSAIDs, Aspirin
3. ***Stress (mainly in ICU patients)

Question 17

***Forrest classification of UGIB

Answer 17

1a: Arterial jet
1b: Oozing
2a: Non-bleeding visible vessel
—> ***require endoscopic intervention

2b: Adherent clot
2c: Black spot

3: Clean base of peptic ulcer

Question 18

Esophagitis / Esophageal ulcer

Answer 18

Causes:
1. ***Acid reflux
- obese / middle age / male

2. Infection
   - **Candida
   - **CMV
   - Herpes virus
   —> esp. in immunocompromised state e.g. DM, chemotherapy, HIV
3. ***Pill-induced (local irritation of pills)
   - elderly
   - psychiatric patients esp. tetracyclines
4. Sclerotherapy-induced (Post-endoscopic intervention)
5. ***Irradiation
6. ***Caustic substance ingestion

Question 19

2. Gastritis, Duodenitis, Erosions

Answer 19

1. ***H. pylori
2. Drug-induced
   - **NSAIDs, Aspirin (both Local + Systemic effect) —> even Enteric coated aspirin can still cause bleeding
   —> almost all patients on aspirin develop mild haemorrhagic gastritis within 24 hours
   —> bleeding is minimal + not clinically apparent
   —> adaptation + healing occurs
   - bleeding can be acute (within first few days) / chronic (after some months)
   - usually **self limiting after removal of drug
3. Alcohol induced
   - acute, chronic
4. ***Stress gastritis
   - ICU patients (respiratory failure, hypotension, sepsis, renal failure, thermal burns, peritonitis, jaundice, neurological trauma)
   —> impaired gastric / duodenal mucosal defence
   - all patients with endoscopic gastritis
   - 2-10% with significant bleeding

Question 20

3. Gastroesophageal varices

Answer 20

• Gastric / Esophageal varices
  —> Gastric varices may accompany Esophageal varices / alone (usually in fundus)
• ***very high mortality (80%)
• 5-10% of cases of UGIB

Causes:
1. **Cirrhosis
2. Non-cirrhotic portal hypertension (e.g. **Splenic vein thrombosis if isolated gastric varices)

Presentation:
1. ***Fresh large volume haematemesis
2. Coffee-ground vomiting (rare)

Question 21

4. Mallory-Weiss tear

Answer 21

• Tear near ***gastroesophageal junction in gastric / esophageal mucosa
• Repeated retching / vomiting
  —> initially no blood followed by vomiting of fresh blood
  —> alcohol / chemotherapy-induced
• Usually ***self-limiting

Question 22

5. Malignancy (gastric, esophageal)

Answer 22

• Malignancy of stomach, esophagus are uncommon causes of UGIB
• Malignancy of duodenum is very rare
• Pay attention in elderly patients
• Bleeding usually ***self-limiting

Question 23

6. Angiodysplasia / Telangiectasia

Answer 23

• aka Vascular ectasia
• **small bowel / **colon > stomach / duodenum
• unusual variant: Gastric antral vascular ectasia (GAVE) / Watermelon stomach (red stripes radiating from pylorus to antrum)

Associated conditions:
- **Elderly
- Cirrhosis
- Chronic renal failure
- Radiation
- Scleroderma
- **Hereditary haemorrhagic telangiectasia
- Aortic stenosis (Heyde’s syndrome), Left ventricular assisted device

Hedye’s syndrome (triad):
1. Aortic stenosis
2. Anaemia
3. Acquired coagulopathy (∵ high shear stress on blood through narrowed aortic valve —> conformational change of vWF —> early degradation of vWF —> making pre-existing angiodysplastic lesions easier to bleed)

Question 24

***Endoscopic intervention to stop bleeding

Answer 24

3 main modalities:
1. Injection with **adrenaline
2. **Heater probe
3. ***Hemoclips (for Mallory-Weiss tear, Angiodysplasia, Dieulafoy’s lesions)

Others:
4. **Argon plasma coagulation (for Angiodysplasia)
5. **Band variceal ligation / ***Sclerotherapy (for Esophageal varices) (rare, ∵ high risk of perforation / stricture)
6. n-butyl-2-cyanoacrylate (tissue adhesive) (for Gastric varices)

Question 25

***Things to do after OGD

Answer 25

Peptic ulcer as an example: 1. ***Continue PPI (infusion / oral depending on severity based on Forrest classification) 2. ***Resume Aspirin ASAP in those with high cardiothrombotic risk once endoscopic haemostasis has been achieved - early resumption of Aspirin does NOT ↑ rebleeding rate with PPI coverage but ↓ mortality due to ACS / stroke - 1-3 days, certainly within 7 days - thrombotic events: 7-30 days, usually between 7-10 days 3. ***Eradicate H. pylori - prevent recurrent peptic ulcer 4. Long term PPI if concomitant Aspirin use

Question 26

If OGD negative but ongoing ***massive bleeding

Answer 26

Usually in setting of ***Fresh melena (indicate bleeding not from upper GI but from small bowel / colon) ∵ if haematemesis, usually indicate missed pathology —> ***2nd OGD preferred if fresh PR bleeding —> usually ***Colonoscopy done first instead of OGD Colonoscopy (+ Intubation of terminal ileum) —> Brisk / Massive suspected small bowel bleeding —> Stabilise patient haemodynamically If patient stable —> ***Red cell scan / ***CT angiography —> Angiography if positive —> Embolisation if positive If patient unstable —> ***Angiography directly (∵ can do Embolisation at the same time) If Red cell scan / CT angiography / Angiography negative —> Specific management: - ***Enteroscopy vs ***Surgery vs ***Intraoperative enteroscopy

Question 27

Angiography

Answer 27

- Detects bleeding at ***0.5-1 ml/min (require ***higher rate of bleeding) —> if CTA / RBC scan negative —> Angiography likely negative —> Localise a site of bleeding in 50-72% of patients with massive haemorrhage but only 25-50% of patients when active bleeding has slowed / stopped - ***Contrast extravasation —> can only be detected at time of ***active bleeding Advantage: - ***Therapeutic also (embolisation at the Same time) Complications: - Catheter site infection - ***Thromboembolism (e.g. ischaemic bowel) - Contrast (allergy, ***nephropathy)

Question 28

CT Angiography

Answer 28

- Detects bleeding at ***0.3 ml/min (can detect much lower rate) - ***Contrast extravasation —> can only be detected at time of ***active bleeding Disadvantage: - ***NO therapeutic interventions (vs Usual angiography) Complications: - Contrast (allergy / nephropathy)

Question 29

RBC scan

Answer 29

- a Radionuclide scan - Technetium (99mTc) sulphur colloid + 99mTc pertechnetate-labelled autologous RBC - Detect ***Slow / Intermittent bleeding which is not shown by angiography —> minimum rate of ***0.1-0.5 ml/min —> as little as ***5ml of intra-luminal blood will give +ve scan —> allow sequential scans + ↑ probability of bleeding site identification Disadvantage: - Delayed scan may identify site of blood ***pooling only but not site of bleeding

Question 30

If OGD negative but ongoing ***subacute bleeding

Answer 30

***Colonoscopy —> Subacute ongoing small bowel bleeding —> Stabilise patient —> ***Video capsule endoscopy (VCE) / ***CT enterography (CTE) —> proceed to ***Deep endoscopy (i.e. SB endoscopy) if positive —> Treat accordingly If Video capsule endoscopy (VCE) / CT enterography / Deep endoscopy negative: —> RBC scan / Angiography / Surgery / Intraoperative endoscopy —> young patients: ***Meckel’s scan

Question 31

Video capsule endoscopy (VCE)

Answer 31

記: for ***Vascular + Inflammatory lesions Setup: - Capsule + Transmitter - Receiver + Recorder - Workstation Use: - Examine ***entire small bowel - Diagnostic only - Complications —> ***Capsule retention Indications: - Obscure GI bleeding - Non-stricturing small bowel Crohn’s disease - Celiac disease - ***Hereditary polyposis syndromes (e.g. Peutz-Jeghers syndrome, Familial adenomatous polyposis with duodenal polyps) Contraindications: - ***Known / suspected GI obstruction / strictures (e.g. Crohn’s) - ***Swallowing disorders - ***Severe motility problems - Uncooperative / Unreliable Disadvantage: - Take 1-2 hours to review footage

Question 32

CT enterography (CTE)

Answer 32

記: for ***Small bowel masses Ingest neutral contrast —> ***distend bowel lumen (vs Normal CT: bowel lumen collapsed) —> detect subtle bowel lesions

Question 33

Video capsule endoscopy (VCE) vs CT enterography (CTE)

Answer 33

Similar yields - VCE has higher yields for ***vascular + inflammatory lesions - CTE better at detecting ***SB masses - negative CTE —> positive VCE in 57% - negative VCE —> positive CTE in 50% —> VCE and CTE are ***complementary examinations

Question 34

Deep endoscopy / Double-balloon enteroscopy (DBE)

Answer 34

- Working length 2m, overtube 1.4m - 240-360cm distal to pylorus - 102-140cm proximal to ICV - Reason for difficulty is elastic nature of looped intestine - Role of flexible overtube with a balloon —> prevent stretching of shortened intestine to allow advancement of scope —> intubated intestine is shortened by gentle withdrawal of endoscope while both balloons at the tip are inflated to grip the intestine Targeted DBE: - Oral route (***Antegrade approach) - Anal route (***Retrograde approach) —> depends on suspected site of lesion from VCE / CTE Advantages: - ***Biopsy + ***Therapeutic interventions possible (∵ with accessory channel + tip deflection capability) - Medical conditions can be treated with non-surgical endoscopic treatments: —> ***Bleeding —> ***Mucosal neoplastic lesions

Question 35

Single balloon enteroscopy

Answer 35

- Balloon attached to overtube only - Up + Down adulation of scope - Low chance of examining whole bowel

Question 36

DBE vs SBE

Answer 36

1. Operator - DBE: 2 - SBE: 1/2 2. Time - DBE: Slower intubation - SBE: Faster intubation 3. User friendly - DBE: ++ - SBE: +++ 4. Depth - DBE: ++++ - SBE: ++ 5. Holding in ICV - DBE: +++ - SBE: ++ 6. Total enteroscopy (chance of examining whole SB) - DBE: 78% - SBE: 25%

Question 37

Meckel’s diverticulum

Answer 37

- Remnant of omphalomesenteric duct, arising from antimesenteric surface of middle-to-distal ileum - ***Rule of 2: —> 2% of population —> M:F = 2:1 —> ***within 2 feet from ICV —> 2 inches in length —> 2% develop complications (usually before age of 2) —> a bleeding diverticulum usually lined by 2 different types of mucosa: Intestinal mucosa + ***Heterotopic mucosa (***gastric, duodenal, ***pancreatic, colonic) - ***Ectopic gastric mucosa —> acid secretion —> ulcer / bleeding adjacent to / just downstream from diverticulum

Question 38

Meckel’s scan

Answer 38

- IV 99mTc pertechnetate (affinity for ***gastric mucosa) —> Scintigraphy to identify diverticula containing ***ectopic gastric mucosa (<25% of cases) —> Meckel’s diverticula lacking gastric mucosa will NOT be seen - Does NOT detect active bleeding (i.e. Presence of Meckel’s diverticulum does not mean it is the bleeding source) - May reveal a ***potential bleeding source if other tests unrevealing (esp. children / young adults)