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CHAPTER | GASTROINTESTINALHAEMORRHAGE
12. An 83- year- old man presented with persistent rectal bleeding and
constipation. He had a past medical history of hypertension, type 2
diabetes, atrial brillation (on apixaban), and prostate cancer for which
he had had external beam radiotherapy two years before.
Investigations:
Haemoglobin 129 g/ L
Flexible sigmoidoscopy Pale mucosa with multiple telangiectasia and contact
What would be your initial management?
A. Argon plasma coagulation
B. Optimize bowel function and stool consistency
C. Rectal formalin
D. Stop apixaban
E. Sucralfate enemas
bleeding extending to 13cm from the anal verge
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GASTROINTESTINALHAEMORRHAGE
ANSWERS
1. B. Presentation with melaena
• The GBS is a pre- endoscopy scoring system used to stratify the need for endoscopic
intervention as well as predict death in patients presenting with gastrointestinal bleeding
• It is better at predicting need for endoscopic intervention compared with the admission
Rockall score
GBS was developed to identify patients presenting with upper gastrointestinal tract bleeding that
would require intervention. It incorporates simple clinical and laboratory parameters to identify
low- risk patients. In a large study of over 3,000 participants, patients scoring ≤ on the GBS had a
0.4% mortality rate and .4% required endoscopic intervention. The score comprises urea, blood
pressure, haemoglobin, pulse, syncope, melaena, history of liver disease, and cardiac failure.
Blatchford O, Murray WR, Blatchford M.Arisk score to predict need for treatment for upper
gastrointestinal haemorrhage. Lancet. 2000;356(9238):38– 32.
2. B. Discharge with outpatient gastroscopy
• Patients with a GBS of ≤ should be considered for early discharge.
The GBS (see Table .) is a validated pre- endoscopic risk score for predicting the need for
intervention in upper gastrointestinal bleeding. Very low- risk patients are unlikely to require
intervention and thus are suitable for consideration of early discharge. Very low risk was originally
dened in guidance from the United Kingdom’s National Institute for Health and Care Excellence
as a score of 0.However, more recent European Society of Gastrointestinal Endoscopy guidance
recommends ≤. A207 comparison study of >3,000 patients with gastrointestinal bleeding
found the GBS to be the most accurate for predicting the need for hospital- based intervention
and mortality. Other risk scores include Rockall (pre- endoscopy and full), AIMS65, and Progetto
Nazionale Emorragia Digestiva scores. The current case likely has a Mallory- Weiss tear and a GBS
of 0, and can therefore be discharged.
Gralnek IM, Dumonceau JM, Kuipers EJ et al. Diagnosis and management of nonvariceal upper
gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
Endoscopy. 205 Oct;47(0):a–46. doi: 0.055/s-0034-39372.
Best of Five MCQs for the European Specialty Examination in Gastroenterology and Hepatology. Thomas Marjot, Colleen G C McGregor,
Tim Ambrose, Aminda N De Silva, Jeremy Cobbold, and Simon Travis, Oxford University Press (2021). © Oxford University Press.
DOI: 10.1093/oso/9780198834373.003.0001
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CHAPTER | GASTROINTESTINALHAEMORRHAGE
Table1.1 The Glasgow- Blatchford score
Parameter (at presentation) Score
Urea (mmol/ L)
6.5– 7.9
8.0– 9.9
0.0– 24.9
≥ 25.0
Haemoglobin (g/ L)
Men
20– 29
00– 9
<00
Women
00– 9
<00
Systolic blood pressure (mmHg)
00– 09
90– 99
<90
Other
Pulse ≥ 00 bpm
Melaena
Syncope
Hepatic disease
Cardiac failure
2
3
4
6
3
6
6
2
3
2
2
2
Stanley AJ, Laine L, Dalton HR etal. Comparison of risk scoring systems for
patients presenting with upper gastrointestinal bleeding: international multicentre
prospective study. BMJ. 207;356:i6432. Doi:0.36/ bmj.i6432.
3. B. Ib
• The Forrest classication grades peptic ulcer haemorrhage in the upper gastrointestinal tract
• It can predict risk of re- bleeding and guide use of endoscopic therapy
The image shows a visible vessel that is oozing blood in the duodenum and corresponds to Forrest
classication Ib. Description of peptic ulcers using this classication is helpful for predicting the risk
of re- bleeding (see Table .2) and the treatment strategy. Other endoscopic features predicting
adverse outcomes or endoscopic failure include large ulcers (>2cm), a large non- bleeding
visible vessel, blood in the gastric lumen, a posterior duodenal wall ulcer, and a lesser curvature
gastric ulcer.
Forrest Ia, Ib, and IIa lesions require dual endoscopic therapy with adrenaline and a second
haemostatic technique (thermal, mechanical, etc.) followed by high- dose intravenous infusion of
a PPI for 72 hours. Forrest IIb lesions with an adherent clot may be managed either by removal of
the clot and dual endoscopic therapy followed by intravenous PPI therapy for 72 hours, or without
clot removal and medical management alone with high- dose intravenous PPI infusion for 72 hours.
Forrest IIc and III lesions require medical therapy alone with oral PPI therapy. All patients should be
considered for eradication of Helicobacter pylori.
Table1.2 The Forrest classication
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CHAPTER | ANSWERS
11
Forrest
classication
Ia Acute haemorrhage Spurting haemorrhage 23.6
Ib Oozing haemorrhage 9.0
IIa Signs of recent haemorrhage Visible vessel 9.5
IIb Adherent clot 7.0
IIc Haematin on ulcer base 9.7
III Lesions without active bleeding Lesions without signs of recent
Adapted from Heldwein W etal. Is the Forrest classication a useful tool for planning endoscopic therapy of bleeding peptic ulcers?
Endoscopy. 989;2(6):258– 262 with permission.
Gralnek IM, Dumonceau JM, Kuipers EJ etal. Diagnosis and management of nonvariceal upper gastrointestinal
haemorrhage:European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 205;47:a– 46. Doi:0.055/
s- 0034- 39372.
4. E. Most duodenal ulcers are associated with Helicobacter pylori
Bleeding Lesion description Risk of re- bleeding
(%)
.
haemorrhage
• Fifty to seventy- ve per cent of peptic ulcers are associated with Helicobacter pylori
• The risk of malignancy in duodenal ulcers is low; therefore, routine histology and follow- up
endoscopy are not recommended
• Pre- endoscopy PPI use for upper gastrointestinal bleeding does not reduce mortality or risk of
re- bleeding
Duodenal ulcers are the most common cause of gastrointestinal haemorrhage. Risk factors
include Helicobacter pylori, smoking, use of NSAIDS, and alcohol excess. Unlike duodenal ulcers,
gastric ulcers are associated with an increased risk of malignancy, and therefore routine biopsy
and follow- up endoscopy after 8– 2 weeks of acid suppression therapy is recommended. Routine
administration of PPIs in patients presenting with gastrointestinal bleeding does not reduce
mortality, transfusion requirements, or risk of re- bleeding. Continuous PPI infusion in selected
patients following endoscopic therapy does have an impact on re- bleeding rates or mortality.
Lau JY, Leung WK, Wu JC, etal. Omeprazole before endoscopy in patients with gastrointestinal
bleeding. N Engl J Med. 2007;356(6):63– 640.
5. D. Haemostatic powder
• Haemostatic powder (e.g. Hemospray– Cook Medical, USA) is eective in managing diuse
tumour bleeding
• Good performance status, non- end- stage cancer, and denitive haemostatic therapy are
predictors of six- month survival in gastric cancer bleeding
Management of diuse tumour bleeding is challenging. The usual modalities of adrenaline,
clip placement, and bipolar coagulation are rarely successful because there is no single target.
Haemostatic powder or argon plasma coagulation may be successful. However, the equipment for
the latter may not be widely available. External beam radiotherapy has a well- dened role in the
palliative phase of gastric cancer bleeding but can take some days to take eect. Placement of a
pyloric stent is not indicated here because the patient is not completely obstructed and this may
aect plans for denitive surgery if she is shown to have localized disease.
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Pittayanon R, Rerknimitr R, Barkun A.Prognostic factors aecting outcomes in patients with malignant
GI bleeding treated with a novel endoscopically delivered hemostatic powder. Gastrointest Endosc.
208;87(4):994– 002. Doi:0.06/ j.gie.207..03.
6. C. SEMS is as eective and safer than balloon tamponade
• The Baveno VI consensus report states that a SEMS is as eective and safer than balloon
tamponade
• Stents can be left in situ for up to one week pending denitive management of portal
hypertension
• Akey benet is that patients can resume oral intake once a SEMS is inserted and the bleeding
controlled
A SEMS (e.g. Danis stent, ELLA CS) can be used to manage refractory bleeding from oesophageal
varices and may be inserted using endoscopic, radiological, or no guidance. Using this technology
avoids the major risk of balloon tamponade, which is perforation secondary to ination of the
gastric balloon in the oesophagus. ASEMS may be left in situ for up to one week but must be
removed whether or not denitive management is planned (e.g. TIPSS or liver transplantation).
The use of stents allows a focus on oral nutrition alongside management of portal hypertension,
and critically does not require the patient to be maintained under general anaesthesia. In contrast,
balloon tamponade should only be used for 24– 36 hours and does not allow for enteral nutrition.
Also, the patient must be cared for in an intensive care unit with tracheal intubation.
National Institute for Health and Care Excellence. Danis stent for acute oesophageal variceal bleeds
(Medtech innovation brieng [MIB85]). Available at:https:// www.nice.org.uk/ advice/ mib85/ chapter/
Summary Published June 209. Accessed September 2020.
7. B. Cyanoacrylate injection
• Band ligation is recommended for oesophageal varices and gastro- oesophageal varices type
(GOV- )
• Sclerotherapy, usually with cyanoacrylate, is recommended for gastro- oesophageal varices
type 2 (GOV- 2) and isolated gastric varices (IGV)
Endoscopic management of gastric varices is guided by the Sarin classication (see Table .3).
GOV- should be treated as for oesophageal varices with band ligation. GOV- 2 and IGV should be
treated with sclerotherapy, most commonly using cyanoacrylate although thrombin is an alternative.
If control of bleeding cannot be achieved endoscopically, then insertion of a Sengstaken- Blakemore
tube or urgent TIPSS should be considered.
Table1.3 Sarin classication ofgastric varices
Variceal type Description
GOV- Extend from oesophagus along lesser curvature
GOV- 2 Extend from oesophagus into fundus, towards greater curvature
IGV- Isolated varices in fundus
IGV- 2 Isolated varices elsewhere in stomach
Tripathi D, Stanley AJ, Hayes PC etal. UK guidelines on the management of variceal haemorrhage in
cirrhotic patients. Gut. 205;64():680– 704. Doi:0.36/ gutjnl- 205- 309262.
CHAPTER | ANSWERS
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8. E. Video capsule endoscopy
• Obscure (overt or occult) gastrointestinal bleeding describes bleeding that persists or recurs
after endoscopic evaluation of the upper and lower gastrointestinal tract fails to identify
a cause
• VCE is recommended as the rst- line investigation and should ideally be performed within
4days of bleeding
Obscure gastrointestinal bleeding accounts for 5% of all cases of gastrointestinal bleeding.
Commonly arising from the small intestine, aetiologies include angioectasia, NSAID- related
enteropathy, small bowel tumours, and Crohn’s disease. Small bowel vascular lesions are the most
common aetiology in overt bleeding. VCE is recommended as the rst- line investigation for small
bowel examination in patients with obscure bleeding. It has a diagnostic yield of up to 60% in this
patient group and is less invasive than double balloon enteroscopy.
A standard capsule measures 26 × mm and transmits images via radiofrequency to a recording
device worn by the patient. Unless bowel obstruction is clinically suspected, cross- sectional imaging
or a patency capsule check is not required. The diagnostic yield is highest if the study is performed
within 4days of a bleeding episode. Anormal VCE is a good negative predictor for re- bleeding
and need for further blood transfusions.
Pennazio M, Spada C, Eliakim R etal. Small- bowel capsule endoscopy and device- assisted
enteroscopy for diagnosis and treatment of small- bowel disorders:ESGE clinical guideline. Endoscopy.
205;47(4):352– 376. Doi:0.055/ s- 0034- 39855.
9. A. Echocardiogram
• Angiodysplasia is the most common cause of bleeding from the small bowel and can be
associated with aortic stenosis, particularly in elderly patients
• Gastrointestinal angiodysplasia is also associated with end- stage renal disease, von Willebrand
disease, ventricular assist devices, and hereditary haemorrhagic telangiectasia
• Multiple endoscopic and systemic treatment options exist with variable rates of success and
high rates of recurrence
The association of aortic stenosis, angiodysplasia, and an acquired coagulopathy (Heyde’s
syndrome) is well recognized in elderly patients although the aetiology is not completely
understood. Angiodysplasia is commonly seen in the ascending colon/ caecum but may also be
found in the small intestine. Other conditions associated with gastrointestinal angiodysplasia include
end- stage renal disease, von Willebrand disease, ventricular assist devices, and hereditary conditions
such as hereditary haemorrhagic telangiectasia (Osler- Weber- Rendu syndrome).
Non- bleeding and non- symptomatic lesions do not require therapy. However, in the presence
of active bleeding or transfusion dependency, treatment should be considered. Endoscopic
management options include argon plasma coagulation, thermocoagulation, and mechanical
haemostasis (clips and band ligation). In patients with persistent bleeding despite repeated
endoscopic treatment, systemic therapy with hormone therapy, thalidomide, octreotide, and
bevacizumab have been tried with variable success. Angiography with embolization or surgery may
be required.
Gerson LB, Fidler JL, Cave DR etal. ACG clinical guideline:diagnosis and management of small bowel
bleeding. Am J Gastroenterol. 205;0(9):265– 87. Doi:0.038/ ajg.205.246.
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CHAPTER | GASTROINTESTINALHAEMORRHAGE
10. C. CT angiography
• CT angiography should be oered to patients with lower gastrointestinal bleeding (LGIB) with
haemodynamic instability after initial resuscitation and/ or signs of active bleeding
LGIB presents a diagnostic challenge, with up to 23% of hospitalized patients being discharged
without a diagnosis. The most common cause in the United Kingdom is diverticular disease,
followed by benign anorectal pathology such as haemorrhoids, anal ulcers, and ssures. In- hospital
mortality ranges from 3.4% up to 20% for those with a blood transfusion requirement of four or
more units.
Patients who remain haemodynamically unstable after initial resuscitation, or who show signs of
active bleeding, should be oered CT angiography prior to targeted endoscopic or radiological
therapy. If no source is identied, the patient should proceed to gastroscopy to exclude upper
gastrointestinal bleeding with fast transit. Surgery should only be considered in exceptional cases,
usually when radiological and/ or endoscopic therapy has failed.
Haemodynamic instability may be quantied using the shock index (heart rate ÷ systolic blood
pressure), with a shock index of ≥ classed as an unstable bleed. An index of < is classed as
a stable bleed and is unlikely to be associated with active bleeding. Stable patients with major
LGIB should have inpatient colonoscopy on the next available list, and patients with minor selfterminating LGIB may be considered for discharge with urgent outpatient investigation.
Oakland K, Chadwick G, East JE etal. Diagnosis and management of acute lower gastrointestinal
bleeding:guidelines from the British Society of Gastroenterology. Gut . 209;68(5):776– 89.
Doi:0.36/ gutjnl- 208- 37807.
11. B. Nuclear medicine scanning with 99m technetium pertechnetate can be
diagnostic
• Meckel’s diverticulum is the most common congenital malformation of the gut and represents
a persistent remnant of the omphalomesenteric duct
• Bleeding occurs due to a rich blood supply from the vitelline artery and the presence of acid
produced by ectopic gastric mucosa
• Surgery is usually required for symptomatic disease
Meckel’s diverticulum is a common malformation of the intestine, usually located within 6cm (2
feet) of the ileocaecal valve. The prevalence is between 0.3% and 2.9% of the general population
and higher in males. The presence of ectopic tissue, usually gastric but occasionally pancreatic,
is associated with symptoms. Gastrointestinal bleeding may occur secondary to acid secretion
from the ectopic gastric mucosa, causing ulceration of the surrounding small bowel mucosa
combined with the rich blood supply to the diverticulum. The vitelline artery is a branch of the
superior mesenteric artery. Intestinal obstruction and acute abdominal pain are other recognized
presentations.
The diagnosis may be made following histopathological examination of a surgical resection specimen
in the context of intestinal obstruction. Imaging modalities such as ultrasound, CT, and angiography
have low sensitivity and specicity but a visible vitelline artery is pathognomonic. Nuclear scans
with 99m technetium pertechnetate can be diagnostic but require functional ectopic gastric mucosa
within the diverticulum. Asymptomatic Meckel’s diverticulum requires surgical resection.
Hansen CC, Søreide K.Systematic review of epidemiology, presentation, and management of
Meckel’s diverticulum in the 2st century. Medicine (Baltimore). 208;97(35):e254. Doi:0.097/
MD.00000000000254.
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12. B. Optimize bowel function and stool consistency
• Fifty per cent of patients will experience some degree of rectal bleeding after pelvic
radiotherapy
• Radiation proctopathy can present several years after cancer treatment and risk increases with
increased dose of radiotherapy
• Endoscopic interventions are not without risk and should not be considered rst line
Radiation proctopathy can be acute or chronic. Chronic radiation proctopathy is likely caused
by chronic cytokine activation leading to ischaemia, brosis, and formation of telangiectasia.
Telangiectasia can heal spontaneously but may take many years. Treatment is targeted at controlling
bleeding. The initial focus should be on optimizing bowel function and stopping contributory
medications, if appropriate.— This patient has a signicant thrombotic risk from atrial brillation,
and apixaban should not be stopped without giving him adequate counselling. Randomized trial
evidence exists for sucralfate, metronidazole, vitamin A, and hyperbaric oxygen therapy. Rectal
formalin and argon plasma coagulation may also be used but are not without risk.
van de Wetering FT, Verleye L, Andreyev HJ etal. Non- surgical interventions for late rectal problems
(proctopathy) of radiotherapy in people who have received radiotherapy to the pelvis. Cochrane
Database Syst Rev. 206;4:CD003455. Doi:0.002/ 465858.CD003455.pub2.
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chapter
OESOPHAGEALDISORDERS
1. A 71- year- old patient was diagnosed with squamous cell carcinoma of
2
QUESTIONS
the oesophagus.
Which of the following is a recognized risk factor for this disease?
A. Alcohol
B. Gastro- oesophageal reux disease (GORD)
C. Helicobacter pylori (H.pylori) infection
D. Non- steroidal anti- inammatory drugs
E. Obesity
2. A 63- year- old man presented to the gastroenterology clinic with
progressive dysphagia to solid food. He was assessed as World Health
Organization (WHO) performance status of 1.
Investigations:
Gastroscopy A malignant- appearing oesophageal tumour is identied at
22cm from the incisors.
Computed tomography
(CT)
neck, chest, and abdomen
Which investigation(s) would be most appropriate to stage this patient’s
A 2cm tumour is localized to the upper thoracic
oesophagus. No distant metastases are seen on this scan.
disease?
A. Positron emission tomography (PET)- CT
B. PET- CT and endoscopic ultrasound (EUS)
C. PET- CT, EUS, and staging laparoscopy
D. PET- CT, EUS, and tracheobronchoscopy
E. PET- CT, EUS, tracheobronchoscopy, and staging laparoscopy
Best of Five MCQs for the European Specialty Examination in Gastroenterology and Hepatology. Thomas Marjot, Colleen G C McGregor,
Tim Ambrose, Aminda N De Silva, Jeremy Cobbold, and Simon Travis, Oxford University Press (2021). © Oxford University Press.
DOI: 10.1093/oso/9780198834373.003.0002
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