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So today, the topic is lower gi bleed. Um So is estimating 33 to 87 per 100 times people, uh usually causes less hemodynamic instability compared to the upper gi hemorrhoids. Uh It can present wide spectrum of presentation from trivial bleed uh to massive hemorrhoids with a shock. Majority of cases bleeding stops during initial resuscitation. Um Lower gi bleeding is defined by bleeding, distal to the ligament of drugs. Uh which means uh bleeding from the small bowel colon rectum or anal area. It accounts for 20 to 30% of all gastro and bleeding. It can have high mortality depending on the presentation. Um So I have a picture as well to show. Uh exactly, I hope anyone can hear me now. Um Where exactly the anatomic location to classify between upper and lower gi bleed is see ligament of tribes. I've got another. Uh Yes, this one here, anatomic cutoff for upper GI ligament of TRS or DJ flexion located in the fourth portion of the duodenum. Uh last two inches connects the fourth portion to the diaphragm near the splenic flexion of the column. Uh We talked a little bit also about presentations briefly, uh it can present as either um hematochezia, which is fresh blood, mixed with stool or melena dark tarry black tarry stool or Frank blood depending on the source of bleeding. But sometimes we need to, to have in mind that despite the color, that might be a different source of bleeding compared to the one that we first uh think first impression is uh because upper gi bleed can also present with bright red bleeding per rectum. And patient is very, very unstable hemodynamically and Melina can be caused by uh also lower gi if it is if it stays, the blood stays long time in the uh lumen, right? And then we talked a little bit about the causes of uh lower gi bleeding the most, let's say well known causes. And these include uh these categories uh erosive vascular tumors, trauma, iatrogenic, or further like diverticular disease, IBD, hemorrhoids, angiodysplasia, ischemic colitis, rectal viruses, cancer, colorectal ana rectal uh following polypectomy, biopsy, colonoscopy, and then some further possible cause me diabetic coagulopathy, uh radiation and diversion proctitis. So first, obviously, we are assessing the patient. Hold on a second. Let me uh I'm not sure if I have a spot here. I yes, initial assessment and resuscitation should coincide uh especially in patients who are in shock. For example, you may get a referral from a and doctors or a nurse. But uh you've got a patient um coming with hypotensive in research, they've bled a couple of times big amount and they have a hb hemoglobin of 65 or 60. So, these patients are in shock obviously and uh they should start resuscitation straight away including transfusion. And I mean, this should not be delayed by awaiting results of investigations like uh other blood tests or etcetera. Also, we should send cross marks about these patients at least 2 to 4 units. Uh if severe bleeding or yeah, low hemoglobin, majority of these patients with lower, if it is a lower gi bleeding will stop bleeding during the initial resuscitation, allowing investigations of the source of bleeding to proceed as an inpatient. Um And then obviously, at the same time, we send off all these uh blood test investigations, ef PC coagulation screen LFT S uh cross mark we mentioned then we have to do an ECG uh to check if this fast af or any other abnormalities uh or ischemia rectal examination is paramount if the situation of the patient allows. Uh I mean, if, if they are relatively stable um chest X ray, um erect xray is possible. Um D perforation, uh ga blood gas uh abdominal X ray. Um and an this is a little bit out of fashion. Uh but I have seen it happening, you know, sometimes it can happen. Um Now regarding let's go back, apologize for this uh back and forth. Now let's say that the patient is a bit more stable, then we have to take, obviously try to obtain as much information as possible. And this includes a good history, taking examination. Uh uh and then while we resuscitate, try to uh do some for um so regarding history, um usually it's a sudden onset, uh painless, we are bleeding. Uh if there is bleeding and abdominal pain, for example, also diarrhea as well, then we suspect you see. So our differential diagnosis is guided a lot by the presentation and by the history and of course by the examination findings, but we start with the history. So if there is diarrhea and pain, then we suspect ischemic colitis IV or infected colitis. If there's a background of weight loss change in bowel habits, then we think of colorectal cancer. If there is a possible history of anemia, fatigue collapse, also, sorry. Also there might be a possible history. So which means that the patient may have been bleeding for a while and didn't realize uh previous history also is important to obtain of radiotherapy, for example, uh in anal cancer or in prostate cancer AAA repair AAA repair because there might be an ent fistula anticoagulants is paramount to know it is very, very important to know if patients are on anticoagulants because then if they are uh then we have to reverse the uh effect. For example, patients on warfarin or patients on do a coagulopathy is important. So we need to check clotting and uh platelet. Yes, the history exactly. So they might not know. Um this is part of, of the examination of stomach if they have a stomach um or a background of peptic. For example, if they are on omeprazole or PPIs, if they're on nonsteroidals, uh steroids, or if they drink lots of alcohol, for example, then your differential diagnosis, thought process will go towards possible ulcer uh or possible um liver cirrhosis or portal hypertension which comes along with viruses. Uh And then obviously, this is a little bit away from lower gi um regarding examination finding, II cannot stress enough. The importance of uh rectal examination called also DR which means digital rectal examination plus minus stros um must be performed in all patients with suspected ti bleeding, not only to assess the color presence of blood, but also the presence of any possible lesions in the anorectal area. Um which will give us um a differential of rectal or anal cancer, also hemorrhoids or fissures, for example, um depending on severity, patient might look clammy, pale, occasionally confused. There might be tachycardic hypertensive as we mentioned, but this is part part of the initial assessment ABCD. Um And if they are like that, obviously, we understand that they may have lost lots of blood and they are in shock. So they need S and S and blood infusion and you might see sometimes not, sometimes these times there might be a major hemorrhages protocol so that we put out in the hospital. And so all the things uh can come and assess a patient including medical team. Uh then blood bank is available for blood infusion. Such if there is abdominal tendon or some examination, you can get some feedback from the patient. Then you might suspect uh ischemic colitis or an inflammatory cause. Um Also on examination, we need to check for uh previous scars from abdominal surgery, stomas. Um because it's, as I mentioned earlier, you need to not to miss, you should not miss uh a possibility for art ender fistula or, or art or sorry diversion or radiation proctitis. There is no, I mean regarding our risk assessment, there is no well validated risk classification system for rectal. Um so whoever patient is in a with hemodynamic instability, uh I mean in shock is high risk for severe bleeding. And to be honest with you, in my experience, I always think of upper g bleed in this case in these cases until proven otherwise. Ok. If I don't have enough evidence to suggest, for example, from the background or person not alcoholic to suggest or previous even bleed to suggest that, then I start thinking about lower. Ok. Now there is a score that has been developed by Dr Oakland, um which uh it's a tool to, it's called Oakland score. It's well established. You may have seen it, you may have come across in documentations, et cetera to assess the need for admission to hospital when you're in doubt if the patient needs or not doesn't need admission, it can be used to stratify II, I've got a reference down. So whoever wants to uh can be used to help stratify patients presenting with a lower gi rate to determine if they can be managed on an outpatient setting. And factors to determine this open score, aids, sex, previous admission for lower gi bleeding, findings on the examination. If they're tachycardic or not. What's the BP, which is very important and what's the hemoglobin level? Up to eight points? Um It is considered relatively safe to allow these patients to go home and investigate them on an outpatient uh basis. And of course, two like certain parameters of the 2 may be a little bit counterintuitive because uh no counterintuitive patient specific because, you know, they give more points if the patient has very high BP where some patients may have like 110, 120 millimeter baseline or um let's say hemoglobin depends, you know, so you have to see what the changes from their baseline and the the score is in a value, you have to see this is from baseline because for somebody uh of 100 or the heart rate, for example, may be a little bit higher, lower. So uh yeah, that's something to take into account. I don't know what the sensitivity and the specificity of the test is. Uh but it gives you a rough estimate. It has a very high score. Uh and of course, any modern stability definitely has to. That's why I mentioned earlier that there's no well validated. It's not a well validated. It's one of the, I mean, the most known score is to be honest that we can use to have a rough as I score, a rough idea if patients can be discharged. Basically, that's the only reason that it exists also to document when you see it's a paper that was published by somebody who Yeah. Yeah. But it, it's good. It's very good. It can reach up to 35 points. I mean, because I looked at um, but, but they say that doctor suggests that if it is up to eight, then it's sort of safe. But of course you have to consider, you have to, it's to individualize every person is different. Um And in my opinion, um the age is very, I mean, and just when you see those patients as a practical team, I tend to the off score you can find them empty or whatever just because to be covered that. Ok, you did a risk assessment. Yeah. Formal risk assessment to say, ok, I'm safe in this special home. So if you go under eight, yeah. Yeah. Up to sort of less than eight or up to eight, not very old, but it's a bit rough as you understand it. It's not very, yeah, that's why exactly I'm not basing my decision on this most of the times in my experience. Yeah. And nobody does it, but it's, it's important to have it in mind that there is a risk assessment for also assessing that putting the things in the scoring system just makes you, you all questions. Yeah, sorry, I don't know. Ok. Yeah, that's what you OK. Let's go ahead. So next, I've got a sl uh regarding uh again, similar uh attempt to classic risk, stratify patients who come to hospital with pr bleeding. For example, as you can see considered discharge, if they are under 60 years old, no evidence of hemodynamic disturbance. If there's no evidence of gross rectal bleeding, of course, this is very vague. I mean, they don't quantify or they don't, what, what does it mean? No evidence of gross or an ob anorectal source of bleeding on pr examination plus sigmoidoscopy or proctoscopy. And then on the other hand, admit if they're above 60 they are hemodynamically and stable evidence. I mean, this makes obviously sense if they take aspirin or nonsteroidal or they have significant comorbidity. So it's not something that uh I mean, I just put it there for the for the knowledge of uh not of, yeah, fine. Uh we discussed about this what to do when a patient presents, which is very important, obviously, and those things happen at the same time. So the most important take home methods and I will stress it out later is at the same time, resuscitate and uh which means treat of course and um assess, sorry, assess and resuscitate. I saw a note you can call because people will come in, you have products. Yes, absolutely not. So yeah, as as I mentioned just now, initial management um along with the yeah, assessment. Well, patients in shock are, is a, is a very good idea obviously to monitor urine output hourly. Uh The aim should be above 0.5 miles per kg per hour. Um repeat F PC or a gas stool chart and involve IU care support if that comorbidities. If a patient has, for example, cardiac or lung issues, correction, correction of abnormal clotting is also very, very important. For example, stop warfarin antiplatelets hold low molecular weight heparin, ok. Um And you need to be and critical care outreach or itu if instability persists further management, uh majority of patients, that's true. Actually, bleeding stops spontaneously once HP is normal and stable bowels open without signs of hemorrhoids, then we have to treat on the same admission. For example, do a hemorrhoid consider sorry, doing a hemorrhoidectomy or a bon. Also. Uh given this channel we discussed about this. Uh in my career, I've seen patients who had hemorrhoidectomy, for example, they excuse we might need another stage or, or something like that if ongoing heavy bleeding um and requiring repeat transfusions. Obviously, we need to contact gastroenterology uh to arrange an urgent uh even out of hours gastroscopy to exclude upper gi source colonoscopy to consider as well or a flexible sigmoidoscopy, you need to consider sorry to contact interventional radiology for act Mesenteric angiogram. Uh And which you know, all these things that I'm talking about happen at the same time. You see, that's why although I'm presenting in this way, they happen at the same time, you, you need to consider resuscitation assessment and also further plans, imaging, what you need to do, what you can do O GD colonoscopy, all that um contact the surgeon. Of course, not, not necessarily colorectal, whoever protect the vascular surgeons. If we know that there is an art, we find out on a scanner that there is a fistula art enteric colon. Let's talk a little bit about some uh diagnostic modalities like colonoscopy. I mean if there is an angiodysplasia or inject adrenaline of bleeding, diverticula or removal of polyps. But this is all uh obviously something that uh doesn't happen all the time, it it has to be very uh individualized and specific patient specific um angiography, which means angiogram. If a colonoscopy fails, then angiogram is thought to be uh preferable in those with massive hemorrhoids. The rate of success uh identifying the source varies considerably from 40. There's a a deva in literature depending on the source of bleeding. Source of bleeding is identified by visualizing extravasation of the contrast material into the lumen of the bowel. Um However, at least 0.5 miles per minute of bleeding is required to solve the extra. That's why many times you hear the radiologist they say has the bleeding stopped? Is it bleeding actively? So they need to know this active bleeding. Otherwise there's no, there's no point in doing uh yeah, sorry, this is for angiogram. But it applies also to the c angiogram in a way because it can show uh external uh and then we can decide based on the outcome of this imaging, whether a patient needs embolization or a vasopressin infusion. And of course, with surgical management, but angiography and um the ir angiography, colonoscopy, how confident is the endoscopies? The operator, it depends on the operating. Yeah, absolutely. Yeah, definitely. So maybe if it's a difficult vessel, maybe they say I don't feel comfortable in embolized. That depends on the like if this colonoscopy wasn't um like easy to arrange, say for at like 7 p.m. then would you would then switch the way around that? You would do it, do the CT angio? Yes, absolutely. That's why you so many times we do see the angiogram first because you can't get a colonoscopy of our Yeah, although I'm presenting in this way, yeah, most of the times it happens the other way around likewise, like with like an acute like upper the fact that the consultant could come in to do a overnight, like they were stable, they are assessing obviously all the time. But is there anyone that would come in and do a colonoscopy as well or is that from side to it would be again a gastroenterologist, um, whoever is doing the bleeding. And it also depends on the, if that being done now versus that being done in the morning, we may not difference because the most important thing here is to resuscitate. If yes, of course, if everything fails, there is a test in the blood, everything don't keep the patient stable, then you have to consider uh direct intervention option. But if it's something that in the meantime, you know, let's say you are bleeding, but they are bleeding comes in at 2 a.m. And if there is no point in doing it now compared to wait in the morning when you have more resources having said that thank you for the comment. Uh Having said that overnight, we have potentially the modality of intervention, radiology. I know it's not local in the hospital. So if we find out on a CT angiogram done, there is for example, an extravasation, you have the contrast going to a vessel, then we can definitely refer for urgent embolization, urgent transfer, blue light and all that. I know it's a fast obviously, but rather than doing nothing, we have to consider talking to you, ok? And if they tell you, you look guys, uh it's better, usually it depends on the patient. It's better to wait in the morning to do a colonoscopy or uh we wouldn't be offering Yeah. So, uh, if you think about George's just make sure the I PS to them, uh, I, because you said some time. But I would, yeah, I would start if I consider referring to Synge, I would do. Yeah. The IP first at the same time, like you to t the box. Ok. So most patients have intermittent bleeding, uh, or can be controlled with no, sorry, non surgical therapist, most in our experience with the bleeding. However, a small minority may need to undergo surgery. We've got a recent example on our unit as well. I won't tell the name but you know, we know this lady in inside room six. So um and it it can be indicated when patient is hemodynamically unstable despite aggressive resistance. For example, I remember this lady had uh how many units, 47 units, transfused units pre op like on the slide, we say more than six units of blood has been required to be transfused, severe bleeding and recurring bleeding. Of course, despite the fact also they did nog day before which was negative for any major pathology. So we excluded the A gi so we had to do something about this ongoing bleeding. There was no on the CT angiogram, there was no extravasation. So that's why they asked our help. You know, when this happens, we have to intervene, it's a low chance but it can happen. Um So whenever have embolization or angiograph have failed or conservative management, then we need to consider surgical, uh, intervention. Um, only 10% of patients with low gi bleeds will require surgery. Nothing to keep in mind. It's the last resource. I mean, if you take that home last less, less. I mean, yeah, I haven't looked to be honest, the recent guidelines but, uh, it could be less. Yeah. I mean, we haven't operated on many. Yeah. Uh, yeah, we don't usually offer any kind of patients with major lower. Yes. Yeah. Yes. Correct. Yeah, thank you. Yeah, that's it. Uh Right. Let's talk a little bit about the role of TX A which is uh controversial. Uh because I found, I mean, there have been a few uh trials, I found AAA randomized hold eight trials called I can give you the reference you want on Lancet published in 2020 which talks about the effects of a high dose infusion of tranexamic. Um the outcome on death and thromboembolic event uh with acute gastro and it doesn't clarify whether it's upper lower gi um so tram acid, they did not reduce death from gastrointestinal bleeding but was associated with an increased risk of venous thromboembolic events and seizures. Proportion of patients with rebleeding was similar in the tram acid and placebo groups. And as far as I could see, um they this international Multicenter trial um was done across 100 and 64 hospitals in 15 countries. Um I'm sorry. And also they, we talk about roughly 12,000 patients. So obviously, we need more data in order to um justify or clarify the role of TX A. Uh But compared so far compared to the um uh the outcome, I mean the role of DXA in um patients with bleeding during a laparotomy. Um it looks like it's not reducing death when patients have, I mean an intraluminal bleeding. Um Now, key points uh any patient with rectal bleeding requires at some point, a flexible sigmoidoscopy or Colonoscopy patient with large fresh rectal bleeding with hemody who is hemodynamically unstable, has an upper gi bleed until proven. Otherwise, um acute bleeds may not initially show an anemia in the full blood count. Another important thing to bear in mind because for example, we admit sometimes and I've got a recent example, we admit a patient with hemoglobin over 100 and 20 who had two or three episodes of last we are bleeding, we are bleeding and the following day HP goes down to 100 or 95. So that's why we shouldn't judge. Uh we shouldn't decide the patient's admission based on the hemoglobin ever. OK. Uh patients who are hemodia stable. Yes, I mean, we know we talked about this already uh Before I do that. Um And my apologies, I should have brought up uh the paper in a algorithm or uh management of uh lower gi bleeding which has to do obviously with simultaneous clinical assessment and resuscitation. Um clinical examination including theory and assess the severity. So there is a very important I think Sarah mentioned in her presentation recently when she was talking about managing acutely unwell patients, we have to calculate shock index which is a ratio between heart rate and systolic BP. And based on this ratio, then we classify further deli either to um unstable patients or stable. If it is this uh shock index is above one, then patient is unstable. So then we consider also doing a CT angiogram and if this is positive, um then obviously we refer patients urgently to intervention radiology or to endoscopy. Um if it is negative, then we go to the uh the second sort of category classification which is if shock index less than one when the patient is stable, we calculate the risk, so score for admission or not. Um And we assess of course, the patient hemodynamically et cetera. As we said, the aids and all these factors. If it is major, I mean many episodes or patients not very stable uh hemodynamically, then we admit to hospital for observation, basically a repeat series of serial uh F PC um hemoglobin level and clotting. And we consider lower gi endoscopy. That's why you see many times we refer for flexi to gastroin. Uh Next available is or a no. Uh If we suspect uh up at the eyelid, then O GD goes fast, of course, minor bleed. Uh then depending on the hemoglobin level. Uh and the way the patient feels and is on how, how they look, then we can uh consider discharge with urgent outpatient investigations like two week weight colonoscopy odd. Um This is an algorithm very important that we need to uh to have in mind observation just because you might get confused in this algorithm was written when Sara uh showed it. So here is the note where you decide and you may get confused to say, OK, the patient is not unstable but keep in mind you also, no, no, it's also the suspect, suspect active bleeding because I would say why do we do see the unstable patients? Uh So you may miss that. Oh yeah, the the active bleed. So I would say the active bleeding should be placed here as a second decision. Those in algorithms are usually decision nodal points. Actually, it's a very good point. Yeah. So it's a shock because out of experience you do it, I mean in sort of yeah uh clinic. Yeah. But yeah, it has to be there. You know somebody who looks at me. Yeah. So calculate shock index or active bleeding. So if it's active bleeding, you go to see the angiogram uh if it's not active bleeding or uh and so if it's stable and you don't suspect um uh active bleeding uh so those active bleeding then you do the recording and everything. OK. So when they made these guidelines, um yeah, they, they, they took it for granted. I suspect that active bleeding goes with just the point of caution just in the Yeah. So if you, if you suspect active bleeding, do you see the angiogram? Yeah. Um and it's published in the gut 2019, I can give you the reference um good based, of course, I think we may have a local. So yes, I don't think we have a local, we don't have a local. That's why I'm presenting. Yeah. Yeah, fine. Um Oh let's go back. I'm sorry, we just, we nearly there. Don't worry guys and I can take questions after uh take home messages. Uh Diverticular is one of the most common. So whenever you hear painless fresh rectal bleeding, first thing you need to consider as a differential is diverticular. So until I mean, in my opinion, until proven otherwise it is diverticular bleeding of cancer. Pardon of cancer? No, no, I mean, yes or cancer. But you know, but what they were teaching us in like uh yeah, the hemorrhoid is the, I mean, unless it's major painless without any findings on Yeah. Yeah. Yeah. But with that, even if you find him or this is something that they will fail as in even if you find, but that is more common. That's what I'm saying. That is Yeah. Uh There should be more specific, sorry. Um The guidelines are we mentioned just now, the algorithm we need to be aware of the shock index in most cases, um the bleeding will stop spontaneously or it will settle. Let's put the patient becomes, you know, more stable hp stabilized and all that in severe cases as high as 20%. That's why it's so important to consider surgical options. If all the others have failed, there's no commonly used, I mean, we also stress that there's no uh commonly used, let's say risking system. But patients with hemodynamic instability are at high risk of poor outcome. Um And a second slide about this uh prompt fluid resuscitation, early surgical review and involvement of critical care is key to the management of unstable the eyelids in the emergency department. So all this would happen uh simultaneously, some low risk patients with minor secondary to benign colorectal disease may be discharged even after they are seen in. So that's why sometimes we decide to discharge them and we're not worried. Um I would say especially for non like under especially Children uh F one F two F one have just run it by the registrar. OK. Um Just give them those information stable or not like a summary. Uh Are you have to send home uh arrange out patient and everything and um yeah, I don't think that any should be on this. Yeah, I mean ii take it for granted maybe. Yeah. Yeah. Uh No. All the the score of uh like the he's like one. yes or but just let them know because you know, you certainly responsibility and obviously none, none of the various treatment options. We have bleeding uh because we see many people coming back with the same bleeding and bleeding again, especially the particular bleed or hemorrhoids. Um colonoscopy performed in an emergency setting within 24 hours of admission is safe and effective. So if any gastro tells you that any gastroentero yet, I shouldn't do a colonoscopy because patient just got admitted. This is not right. There should be an imaging intra intraluminal uh view. Um And last thing, surgical intervention is required. Yes, one patient unstable. Uh These are the references. Thanks for your attention. Any questions please, you any questions from the online audience, please let me see. Um I think also asked that because we had a case uh well, not really recent but this guy kept coming for recurrent pr bleeding um when they are stable and everything uh check if they are uh allowed if they are happy to take blood products because you know, we have, you may have Jehovah's witnesses. Oh yeah, because we have this patient that always consent before transfusion. Yeah, it's something that I should have been very important because some people may say no I want or I want something alternative. Yeah, uh comes up on and you have to consent either way. I mean, there's a book and also um I think we are apart from the major uh I mean, I mean, apart from the A&E setting, people that we go to primary care should be uh familiar with that because they will have a lot of patients that may come in. They will say, OK, it's mine or go to the TP. So uh I would encourage them. Yeah, that's a very good. However, however, um you know, you are talking about filtering for these patients in the community or in the practice, I mean, this is a bit challenging because even if patient is treated in a way that OK, you don't have to go to the hospital if they go home and they start having massively faint. That's the always trying to sense to be on the safe side. Although they might be stable or sort of a little bit low BP, they send all people to hospital, you could do it if you have a super stable patient, young. Uh Yeah, I mean, you depend on again, I would call her, you cannot apart from the ideal patient that could stay at home. Anything else, any old patient, anything like that? Uh You can, should definitely send, you cannot send even without discussion. It's one of those things that I would say send without discussing. OK, I would like to ask everyone is, is, is, is all we presented here clear. I mean, what, what you have to do when somebody presents with the bleeding. Yeah. Any questions, what's the to clarify, assess and at the same time as much as you can. Sometimes it's not easy because patient may be like collapsed or you don't. Yeah. Yeah. And these patients will be, if they, they will be, they will be in a normal environment. So first thing you cannot, that's why the fluids, blood about the uh a patient in research with pr bleeding. You think it's probably a bad bleeding if they and this may happen everywhere. I it might, it might happen on the woods, it happening in outpatient. Say that. So you need to be prop as much as possible. All right, no other questions, I guess. Thank you everyone. Thank you very much. All right. And I, and I will upload uh, the video and uh, the slides, uh, sometime today. Ok, guys. See you soon.