12.11.27 GI bleeds


  • Haematemesis

    • Start: Nose/Mouth

      • cf Nosebleed

    • Finish: Ligament of Treitz (D3)

  • Melena

    • Start: Nose/Mouth

    • Finish: Iliocaecal valve

  • Takes about 14 hours for blood to be broken down within the intestinal lumen

    • If transit time is less than 14 hours the patient will have hematochezia

    • If greater than 14 hours the patient will exhibit melena

Ligament of Treitz

  • Connects the duodenum to the diaphragm

    • Inserts into the third and fourth portions of the duodenum and frequently into the duodenojejunal (DJ) flexure

  • When it contracts, the suspensory muscle of the duodenum widens the angle of the duodenojejunal flexure, allowing movement of the intestinal contents


  • Sinister symptom

    • Syncope/pre-syncope

    • e.g. Went to the toilet, Saw blood, Stood up, Fainted

Relevant drugs

  • NSAIDS, aspirin, warfarin

  • Beta blockers - Mask reflex tachycardia

Bad prognostic features

  • Heart failure

  • Ischaemic heart disease

  • Renal failure

  • Liver failure

  • Metastatic cancer

Perforated DU

  • Used to do excision and end-to-end anastomosis (Billroth procedure)

    • Vulnerable to cancer and re-bleeding

  • Now overlay layers => Better

Aorto-gastric fistula

  • From inflamed aorta

    • e.g. Rejection of AAA stent

  • May mimic ulcer presentation

    • But endoscopy negative and omeprazole doesn't help

  • Then bleed catastrophically

Stigmata of chronic liver disease

  • Spider naevi

    • Fill from the centre

  • Gynaecomastia

    • Liver can't metabolise oestrogen

  • Loss of secondary sexual hair

  • Ascites

  • Caput medusae

  • Everted umbilicus

  • Jaundice

Liver and inflammation

  • Liver failure => Loss of inflammatory response

  • Serious risk of asymptomatic spontaneous bacterial peritonitis

    • Must check with an ascitic tap

Rockall score

  • A - Age

  • B - Blood pressure fall (shock)

  • C - Co-morbidity

  • D - Diagnosis

  • E - Evidence of bleeding

  • Interpretation - Mortality

    • 1 - Nil

    • 2 - Nil

    • 3 - 5%

    • 4 - 5-10%

    • 5 - 5-10%

    • 6 - 5-10%

    • 7+ - 10-35%

  • Most elderly patients are 25-50% mortality risk from a GI bleed!

Things distinguishing an enlarged kidney from an enlarged spleen on examination

  • The spleen has no palpable upper border

    • The space between the spleen and the costal margin (which is present in enlarged kidneys) cannot be felt

  • The spleen has a notch that may be palpable

  • Spleen moves inferomedially on inspiration while the kidneys move more inferiorly

  • Spleen not balottable unless gross ascites present, but kidneys are because of retroperitoneal position

  • Percussion note is dull over the spleen but usually resonant over kidneys due to overlying bowel

  • A friction rub may be heard over spleen but not over kidney as it is too posterior

Management of GI bleed

  • Fluids while you're waiting, but they really need BLOOD

  • Cryoprecipitate

    • Expensive but great at replacing clotting factors

  • Vit K, platelets

  • Sengstaken-Blakemore tube for varices

    • Balloon tamponade

    • Just inflate the gastric (not the oesophageal) balloon, to avoid necrosis

  • Terlipressin

    • Splanchnic vasoconstrictor

    • Reduces HPV blood flow => Less bleeding from varices

    • Beware gut ischaemia!

  • SIRS

    • Systemic inflammatory response syndrome

    • => BP rise in response to infection

    • Can cause varices to pop

    • => Manage varices with antibiotics to treat the underlying cause

  • Lactulose

    • Used to drop gut pH

    • Kills bacteria to prevent ammonia production

      • May not be converted to urea if your liver's broken

      • => Encephalopathy

    • Better than using antibiotics (c.f. C. diff)


  • Failed discharge is readmission within 48 hrs

  • Clot the size of a fist = 500 ml of blood

  • Courvoisier's law

    • Because the gall bladder with stones is usually chronically fibrosed and therefore incapable of enlargement

  • MGMT of Mallory-Weiss tear

    • Observe o/n then home

    • So don't misdiagnose as e.g. a bleeding ulcer, which means 5 days in hospital!

  • Peptic ulcers

    • Oesophageal

    • Gastric (=> Cancer)

    • Duodenal

  • Be careful coffee-ground vomiting really is!

    • Not just something brown they've eaten

  • Melena and haematemesis are both equally life-threatening

  • Stomach pH is lowest around the pylorus

  • Shutdown? => Femoral

    • Don't try to put a central line in the internal jugular as you'll cause a pneumothorax

  • Raised urea:creatinine after a bleed (high-protein meal)

  • Lots of antibiotics interfere with warfarin metabolism and raise INR!

  • The most common GI bleed on the ward is ULCERS

    • NICE do not support the use of PPIs pre-endoscopy

    • But it can take days to get one done so give them anyway

  • High INR alone doesn't cause a bleed

    • Investigate the CAUSE

  • TIPS

    • Transjugular intrahepatic portosystemic shunt

    • Establishes communication between the inflow portal vein and the outflow hepatic vein

    • Used to treat portal hypertension

  • Hb takes a while to fall following a GI bleed

    • So check again in 4 hours

  • URINE OUTPUT as a marker of volume status