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Hi, everyone. Can you hear? Can you guys hear me? Mhm. Surrounding my spring. Has it a bit? Ok. I will sh the screen out. Hm. Hi. I'm kind of the doctor's currently working in Sheffield today. I'm going to go through a case of lower bleed with you guys. So this will be an interactive session. So I will ask some questions along the case and you, you guys are free uh feel free to put your answers out in the chat box and I will have a look later on. Ok. So yeah, to today you will be a a foundation doctor doing your on call shift in the acute surgical unit. So here comes the patient. So it is a 67 years old woman coming due to passing out blood from the back passage for three days. So with this presentation, what further question we like to ask? And why do I why do you want to ask those questions? Could guys just put it and answers in the chat box? Mhm. Is the slight moving now. Press light show at the very top. Uh If you go to the very top of your your screen and press slide show and then from beginning and then that should work. Is it working? Now? You tried changing the slides? I have to change that slight. Is it working out? No, it's not changing. Mm Yeah. Hi. This is Jing Jing from medical support. Can I check if you're on a Mac right now? So no, I'm no, I'm on a window. Ok. Um Are you sharing your entire screen or sharing your window? Um and sharing the window? Ok. If you go, if you stop sharing like that and you share your entire screen, that should work better. Ok. Yeah, I can see my screen now. Yeah, we can, is it working now? It is working now? And that will be I will be having issues to see. It's OK. I will just come out and see the checkbox later on. Ok, sorry. So I will restart. So you are a foundation doctor working in acute surgical unit today and here is the patient is a 67 years old. So he's she's saying she's quite worried today because she has been passing out blood from the back passage for three days. So what further questions would like to ask? And why do you want to ask the question? You guys can put the answer in the box and we just come out and have a look at the checkbox. Yeah, so it's saying he will ask that is the blood fresh or thick. Um Yeah, it would be a good question. But instead of asking that I ask, what is the like color of the blood? Is it like bright red or black color? Is it any pain, loose stool or any constipation? Yes. Any associated symptoms, tiredness. Yes. Because you want to know if the patient is anemic now. Vomit color. Yes. Vomiting. Yes. But why, why do you want to ask about vomiting? Mm. And the quantity and the amount of the blood? Yes, because you want to justify how serious the bleeding so that you can roughly know what, what is the management you want to give any blood thinning medication? Yes. Warfarin is very important. Weight loss, fatigue, constitution. I think that red flag for malignancy. Yes. Read it. Trans pan dyspnea like had anemia from blood loss. Yes. And when is the blood? Yes. Is it wiping mixed with stool? Is it at the end of passing the stool? Yeah, it's very important because every this will help to differentiate whether the blood come from the inner part of the grate or from the outer part of the foot of the grate. I'm not pretty big. Yeah. These are all crucial questions you want to ask. So the most important question we would like to ask that first of all, to be the color of the stool, the the color of the blood. Is it Melina or hematochezia? So, do you guys know what is the difference between these two? Yes. So Melina is like digestive blood. Yeah, that what I can say is digested blood in the stool. So it was shows at a black stool. So when people tell you, um he has blood heart like blood stool, have to always ask, is it like very solid stool or is it like very liquid stuff? And it's t of foul smelling because it helps to differentiate whether it's a Melina or it just because of some like because of iron tablets. So for those who have like hot blood to it, normally due to iron tablets, like side effects of iron tablets. Instead of me and Melina, there is a very strong smell. Once you have smell it before, then you won't forget it. And it is a very sticky black like tar too. And it usually, it indicates there's some bleeding in the upper dry tract while hematochezia is like fresh bleeding in the stool. So it can be either maroon color or bright red color. And it usually indicates there is some bleeding in the lower dry tract. But, but it might, I massive upper dry bleed. It can also present as a hemato because when there is massive upper g, the blood just pass through very rapidly. So they do have enough time for like for the digestive enzyme to digest all the hemoglobin in the blood to form a blood stool like in. So we just run past your gi tract and pass like passing out from your back passage as a fresh blood. So if the patient come due to uh presented with clinically, he more than he he more than unstable and he also having to, you have to think about upper. Mm Yeah. So which part we consider upper gi and lower gi. So it depends on the location, the anatomical location in relation to the amount of. So ligament of tract is a fibrous tissue that attach to the Jordan. So anything above that like your Jordan, your stomach, your esophagus, your mouth, oropharyngeal space. Everything we consider as upper gi tract and lower, anything be beneath, it will be lower gi your, your lb, your rectum and your anus, everything will be lower gi. So there are many causes of Melina. So the most common cause would be diverticular disease. So normally the patient will come in, come in presented with um pen pain. If it is in diverticulosis, sometimes they will be having some down intermittent like achy pain in the left, lower region. Sometimes it can also be on the right side, especially in Asian origin. And then the next one be dysplasia. For example, like all the every malformation and it runs in family colitis, any form of colitis, we cause Melina like there are three types. So like ischemic um inflammatory and infectious colitis. So for ischemic colitis is usually happens in those people who have like cardiac disease. So or in patient who come in with sepsis. So there is not enough blood supply to the large bowel and it cause some ischemic ischemia there and it tend to bleed and for infectious disease can be like shigella salmonella. And so it's very important to ask for recent travel. And how about the diet? Is there any recent like raw fish? Some salmon that things and inflammatory includes IBD like inflammatory bowel disease, colitis. So you can ask for any past medical history of IBD or any family history, weight loss, fever, abdominal pain, colon cancer have to consider it in every elderly patient because it's an an elderly coming with chronic bleeding from the back passage and anorectal disease. For example, hemorrhoids, either internal or external and fissures and electrogenic. Now, so you have to ask about the recent polypectomy like recent mm radiation. It can cause radiation or recent biopsy from the colon. It will, it will cause some bleeding like in around 30 days like within 30 days of the procedure. And it is usually self resolved coagulopathy. For example, in those with chronic liver disease or any one on anticoagulant, it can also cause bleeding. If it is not like under control, it's over coagulant and upper joint bleed, as I said before. So upper joint bleed, most common cause of petty ulcer disease. Sometimes in people with cirrhosis and the most common cause of it esophageal vice bleed. So yeah, mind this all like differential diagnosis. And you can ask the questions to r at every causes of me. So these are all the distinguishes mentioned just now. So you guys have, can have a look afterwards. So history taking. Yeah. So you guys have mentioned some of the question you asked with this kind of presentation. So first of all, we will start from the bleeding, the presenting complaint. So we want to know how fast is the onset? Is it the first episode? Is it a recurrent one? How quickly is it an acute or chronic bleeding and color? Is it melena or hematochezia and the quantity of the bleeding? Because in massive bleeding, um you normally the patient will be very unstable and you will have to like do something quicker in relation to stool. Is it mixed with stool or just on wipes? Like some people with very panic and say is having bleeding? But when you ask, it's just on wipes. So it's not that concerning because most commonly it's due to an AFI which is painful or it's just hemorrhoids, which is and associated symptoms. Any abdominal pain could be in IBD diverticulitis or the inflammation, colitis. Um weight loss can worry about cancer, vomiting, diarrhea, infection, fever, any inflammation, infection and MS associated with cancer and the timing of the bleeding. Is it constantly like continuous bleeding? It just intermittent on and off or only during defecation. Ok. And after this, we will ask about the past medical history, IBD diverticulosis disease, chronic liver disease, heart disease throughout like colitis, um diverticular disease. Yeah. Any bleeding from the upper gi tract called neuropathy and recent bowel procedure like polypectomy, radiation, radiotherapy and also biopsy from the bowel drug history. The most important one is the anticoagulant because it's very easy if you can spot if the patient did because of the anticoagulant because it, it can be easily reversed, especially on Warfarin can give in IV. And it, it can like it will respond very quickly. And sex and recent radiotherapy family history, IBD and bowel cancer, social history, asked about diet, um like recent high risk diet, like raw fish buffet, some salmon and then also ask about the risk factor for bowel cancer, like red meat, low fiber diet, recent travel smoking status related to all the cancer and uh or sis and the performance status of the patient because sometimes if it is very severe, you might need to do some invasive procedure. So you, you need to consider if the patient is fit for the like invasive procedure like surgery, colonoscopy. Ok. So you asked about those questions and Mrs Lee told you it is bright red blood mixing with the stool, there is no mucus and its spontaneous in the day and it normally soak half a pack in a day and has been having that intermittently for like past two years. But for the past three days, it is becoming constant. It's like continuous bleeding for the past three days and associated with the pain in the lower tummy. Also, having diarrhea usually should be having constipation, no vomiting, bad feeling, nauseous, no fever, no weight loss, but not been eating and drinking much because of the pain and the bleeding. So past medical history has IBS so that she has constipation and gastritis, osteoarthritis, hypertension surgical history. Nothing remarkable. Just the knee replacement drug history already on LSO for gastritis for the OA and I Ibuprofen gel for the OA as well. And family history of bowel cancer, social history, like she didn't usually eat high high fiber diet and she likes red meat. There is no recent travel and she smokes 10 cigarettes per day for 40 years. She is usually fit and well. So the nurse do the vital on the patient. So the vitals are all stable aside from the heart rate. He's a, she's a bit cardic. It's 100 and five bit bits per minute. Otherwise BP is a bit low temperature is fine. Respiratory rate is fine. So, what will you do next with discount presentation and the vitals? Yeah, I, since I examine, um, what examination would you like to do? Yeah. So we'll do a general examination, abdominal examination and D I Yes. So, so and mm I didn't put a general examination here, but you would like to see if the patient is pale. Has a pass. Is it very fast? CRT? And is the, yeah, it's the patient showing signs of breathlessness and then you'll move on to abdominal examination. So you palpate the pa patient's tummy and it's soft, non tender. There is no signs of peritonitis peritonism. There is no guarding, no rebound tenderness and you can't feel any mass and pr examination. So you can. So for pr examination, you can always check to like divided into two external and internal. So external, you will look for any hemorrhoids, any fissures, any skin tag that's not on this patient. And for internal, you just insert your fingers and see if you can feel any prostate prostate enlargement if it is in um new patients and then you have and then feel any impetus stool, any loose stool in the rectum. Then afterwards you examine your growth. Is there any bleed? Is there any blood? And what's the color of the blood in the stool? So for this patient, there is no external hemorrhoids or fissures and there's some bright red blood mixed with the yellow stool on the. So it's clearly is hematochezia and the it is not due to anorectal condition because there is no um it could be due to internal hemorrhoids, but it is not due to external hemorrhoids or features and also congested remind you for any giant bleed like no matter it's upper gi or lower gi always do apr examination because you want to make sure it is, it is a true G. Ok. So at this point. So can anyone tell me which will be your differential diagnosis? From this diagram? I put the diagram on for 30 seconds and then I will like feedback to see the answers. OK. So what would you, what do you think will be the first differential diagnosis in your mind? Colon? C mm Yeah. Could be one of your diagnosis because of the family history, but there is no weight loss which that makes you think in my be a little bit down in your differential days. Diverticular disease. Yes, is the most common cause. And due to the risk factor, the patients have like um having intermittent chronic bleeding and low fiber diet and also smoking history. Yeah. So the first differential would be diverticular disease because of the risk factors and the present like the history of presenting complex. The second one may be colon cancer. Yeah, because of the um old age family history, also chronic pa and chronic bleeding, but it's also a bit unlikely because there is no weight loss, no loss of appetite, no messed up. It could be also enjoyed this place. Yeah. And can be also colitis but it is a bit low in the list because there is no fever and there is no um history of heart disease. No recent travel, no high risk diet and nonfamily history of IBD. Hm. Yeah. So I will show you. So what investigation we would like to do in patient presenting with Melina. Mm. What do you mean D2 and three? Is it day two or three or two other than two like second of the path do. Yeah, colonoscopy will definitely do that in every patient coming with bleeding and bloods. Ok. Ok. Yes, you will do the urgent colonoscopy and blood. What blood do you want to order? Yes. So we will do F BCU and E with good and safe C RP. Um What do you mean even blood symptoms of anemia? Is it regular routine blood? Yes. If you are thinking of infection, um you do ACR P but we wouldn't normally do E sr because it is a chronic inflammatory marker. So it wouldn't be useful in diagnosis like acute infection, CBC and colonoscopy. Yes. Yeah. So for the blood, yes, you do FBC to make sure the patient is not anemic and to also monitor the B trend. And if you are thinking of uh infection, it is also very useful to look at the white cell count and you and e to look at the especially to make sure it is not upper join bleed because it will be raised in upper join bleed and also the creatinine as well because sometimes when people like having not eating and drinking and having massive like having bleeding continuously, they will be a bit dehydrated. So it would cause AK as well. C RP is if you are thinking of infection or inflammation, coagulation profile is very useful, especially in those people taking coagulant anticoagulant, just to monitor if they uh over a unit or not, then you can be co correct any coagulopathy from there. I have to, to make sure the patient is not in, does not have any chronic liver disease which, which can like derange the coagulation profile and blood culture. If you are thinking of infection, then you might need to do a blood culture that is plus minus. And the most important thing in bleeding is you have to do do good and safe in every patient. And if it's in likely unstable patient, you also want to cause you also want to do a cross match still good and safe so that you can have the blood transfusion urgently. And other things you can think of is like stool culture. If you are thinking is infection like fecal count, protecting if you are thinking of IBD and the gold standard would be endoscopy. So if you are thinking is due to lower gi then you will do a colonoscopy. But if you are thinking it's upper gi you do like both upper gastroscopy and also colonoscopy. And if CT angiogram, if the patient is unstable to or does not fit enough to have the endoscopy, then go for CT angiogram to see where the bleeding is and we can do some intervention as well to stop the bleeding. So in this case, which so in this case, we do this highlighted um investigation FB ACP end because there is no signs of infection and there is no fever and you don't think it's due to IBD and the patient is stable enough for the endoscopy. So, um investigations come back. So the HB is 10 white cell is normal, is normal. C RP is a bit raised, could be due to some inflammation in the bowel and coagulation is normal is normal and colonoscopy is still pending for the patient to come back from the procedure. So at this point, what management plan will you write in your admission summary? Ok. Mhm. Ok. I think it's quite tricky. There's nothing else we can do. Now. Is there aside from like frequent monitoring? So the management will be like frequent observation monitoring to make sure the patient is stable, especially we will see if there is any drug in BP. Because if you indicate there is not like active bleeding, then we need some like active acute treatment for that and monitor for further bleeding. If it is stable and there is no further bleeding, then we can safely discharge the patient home after one day or two days, monitor the hash B and daily to make sure it's stable. And if it is low, then you might need to consider blood transfusion and correct any coagulopathy, not in this patient. But in general, if there is any er coop for example, the patient is on Warfarin and, and I is very high. Then you need to consider I VV care. Or if the patient is on heparin, then you can give some to reverse the conation effect and dec effect. And I need fluids just to maintain ABP because the patient is like losing out fluids, the blood from the bad passage. So you want to give some maintenance fluid to make sure the patient is not dehydrated and awaiting colonoscopy result to come back. So the patient come back from the colonoscopy. And this the report, it says there are three active bleeding, no knotted in the sigmoid colon and hemodes achieved with epinephrine injection. So it's clearly that there is um is due the bleeding is due to diverticular disease and it fit to the presenting is having chronic intermittent pain and suddenly it become worse, constant pa uh bleeding. And we also asso associated with the dull achy pain in the tummy and also mm Yeah. And hemostasis a epinephrine injection. So for endoscopy, when, when we do a colonoscopy and find and found the bleeding site, we can do something like some therapeutic like methods to stop the bleeding. One of them is epinephrine injection. So just like flush and inject the, just flush it and inject the adrenal adrenaline like um at the at the surrounding of the bleeding site that it const the vessels and stop the bleeding. Sometimes if there's like polyps or any even in diverticular disease, we can also use the ligation and bending to or clipping to just clip the polyps and stop the bleeding. So in this photo, you can see on the left top there is active bleeding, you can see the yellow arrow there. So there is this the active bleeding point, you can see blood, it come is coming out from this point. And this one is just a blood clot. This also show blood clots which indicates like like recent bleeding. And once you remove the blood clot, you see a deep bleeding coming out from here uh from the clot side. So after six hours, the nurse rang you saying that has deteriorated. So this is the now. So the heart rate become 100 and 10 respiratory rate is 25 M BP is very low is 84/52 temperature is 37 and the patient looks, looks pale and the peripheries are all cold. So with this kind of vitals, what do you want to do? So this will be the like very common um see like scenario you have given you clinical practice because some like, yeah, the nurse will bring you for the unstable patient and ask you to assess them very urgently. Yes, she is slightly likely acute bleeding. Yes, you do a a assessment including G IE M BBg. Yes, this is the correct answer. Mhm So we do a to e assessment. So for airway, the patient is talking to you. So the airway is patent. You are not that worried about that. And B the patient is a bit breathless me. Um It still saturating well on room A and chest are clear and see is four seconds now and peripheries are very cold pass is a bit weak but it is regular. It is 100 and 10 BPM is normal and the the pupil is bilaterally. Patient is a bit drowsy BM is fine and abdomen is the abdominal examination is unremarkable but you notice there is some bleeding on the pet is like full pad soak in the blood. However, there is no active bleeding when you examine the patient. So you think the patient is in active bleeding and is in hypovolemic shock now, because the BP is very low and heart rate raised, everything is raised the kidney and you do have BBg HB dropped to 68 now. So what would you do? No, with discount presentation? Yes. Um Initial the major hemorrhage protocol give blood product city and contact on G. Um Yeah, but I wouldn't I the major hemorrhage protocol because the patient is not actively bleeding now. But I definitely give. So first of all, we maintain ABP first. So I give I VB now and then I will also and afterwards I will bring blood banks to order two units of blood urgently so that can give blood transfusion. Then I will also, then you also need to arrange a urgent an urgent CT angiogram because the patient hemodynamically stable and she has failed the inter like she has done the intervention during the colonoscopy and it fails. So it's kind of like two indication for CT in your room as well. And then um instead of inform onca gastroenterology, I will inform the on call surgeon, surgical consultant because it's um it's clearly that the bleeding is from the lower part. So it's more do the same colon. So I will definitely on bring the on call, consult surgical consultant and see if he wants to do anything like for example, surgery. Mhm. So yeah, we've done a CT angiogram very urgently and it shows there is one active bleeding never miss during the endoscopy in the distal descending colon. And yeah, they did an arterial embolization and um and the patient has become stable afterwards to the patient was remain in inpatient for a few days and there is no further bleeding after all the intervention and repeat has B and urea every day and it is improving and is stable and urine remains normal and she is quickly stable afterwards, she was discharged home. So there are other management to consider. So if there is like massive active continuous bleeding, then you will need to initiate the major hemorrhage protocol. So we will bring for two and initiate a major hemorrhage protocol and then the blood bank will like prepare all the blood products for you urgent, very urgently within like five minutes, then you can give the patient blood transfusion immediately. So surgery might be an option, but you is a last resort. So if it's still, if the bleeding still can be controlled with all the intervention I mentioned just now like colonoscopy, ct angiogram with embolization, then we might need to cut the bowel out, especially in those with colitis. So yeah, that's it for today. Any questions? Um If there is no question, thank you very much for listening. I hope this session is useful and um please take a moment to fill out the feedback form and then you can have your attendance certificate afterwards. Thank you very much for listening.