the clinical approach to the most frequent acute conditions in abdominal surgery gi bleeding adam...
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The Clinical Approach to the Most Frequent Acute Conditions in
Abdominal SurgeryGI Bleeding
Adam Janiak
Upper GI Bleeding
Proximal to the ligament of Treitz Causes:
1. peptic ulcer disease (1/2 – 2/3 UGI bleeding)2. esophageal varices (10 percent)3. hemorrhagic gastritis4. gastric varices5. nose bleed6. Mallory-Weiss tears7. reflux esophagitis8. gastric neoplasms9. hematobilia
Presentations of UGI Bleeding
Severe bleeding hematemesis 25 %
‘red blood’ hematemesis ‘coffee ground’ emesis
hematochezia 15 % hypotension
Gradual bleeding melena 25 % (50 – 100 cc of blood will render
stool melenic) Occult bleeding
positive tests for blood in the stool
Initial Evaluation of UGI Bleeding 1
Perceived rate of bleeding Degree of hemodynamic stability Outpatient basis
hemodynamically stable no evidence of active bleeding or
comorbidities endoscopic findings favorable
Hospitalization evidence of serious bleeding
Initial Evaluation of UGI Bleeding 2
ABC History of or current:
hematemesis melena hematochezia
Lab Tests: CBC blood chemistries (liver and renal function
tests) prothrombin time (PT) and partial
thromboplastin time (PTT) blood typing and crossmatching
Initial Evaluation of UGI Bleeding 3
patient stable & no evidence of recent or active hemorrhage – proceed with the workup.
patient stable & shows evidence of recent or active bleeding – large-bore IV line before workup
patient unstable – immediate resuscitation
Resuscitation in UGI Bleeding
secure airway for adequate ventilation (Oxygen as necessary) large-bore I.V. line for lactated Ringer solution urinary catheter for urine output monitoring blood infusion as necessary coagulopathy correcion
It is all too easy to forget these basic steps in a desire to evaluate and manage massive GI hemorrhage!
patient unstable & continues to bleed – intraoperative diagnosis
laparotomy through an upper midline incision anterior gastrotomy pylorus-preserving duodenotomy
Clinical Evaluation of UGI Bleeding
History known causes of upper GI bleeding (e.g., ulcers, recent trauma or
stress, liver disease, varices, alcoholism, and vomiting) use of medications that interfere with coagulation (e.g. NSAIDs,
dipyridamole) or alter hemodynamics (e.g., beta blockers and antihypertensive agents)
cardiac history for assessing ability to withstand anemia Physical Examination
jaundice ascites tumor mass bruit from an abdominal vascular lesion
Nasogastric Aspiration bloody aspirate – EGD clear, nonbilious aspirate – bleeding site distal to the pylorus clear and bile-stained aspirate – source of the bleeding is unlikely
to be the stomach, the duodenum, the liver, the biliary tree, or the pancreas
Upper GI Endoscopy 1
almost always reveals the source of UGI bleeding
requires considerable skill hematemesis – emergency EGD (within
1 hour of presentation) melena – urgent EGD endoscopic control of bleeding sites
injection thermal coagulation mechanical occlusion (clip application or
variceal banding)
Ulcer Appearance and Prognosis
Appearance Prevalence % Rebleed % Mortality %
Clean base 42 5 2
Flat spot 20 10 3
Clot 17 22 7
Visible vessel 17 43 11
Active bleeding 18 55 11
Other Tests
enteroclysis + RTG Tc tagged red cell scan arteriography video capsule endoscopy intraoperative endoscopy
Endoscopic Therapy in UGI bleeding
Effectively reduces Rebleeding Need for Surgery Mortality (by meta-analysis) 10 – 20 percent of patients have
rebleeding after (initially successful) endoscopic therapy
The Role of Adjunctive Pharmacological Therapy
Clot stabilization: at a pH of above 6.0 pepsin is inactivated and cannot lyse clots
Effective clotting may not occur at a pH of 5.9 or lower
Antacids, iced saline gastric lavage and H2-blockers and other interventions are ineffective in reducing rebleeding rates
Proton Pump Inhibitors
NEJM 1997: high dose oral omeprazole effective in reducing rebleeding rates. No endoscopic therapy performed in this study from India
Two multicenter trials from Scandinavia showed benefit of high dose I.V. omeprazole (1997)
Taiwanese study of 100 patients randomized between IV omeprazole and cimetidine. Intragastric pH was around 6.0 for first 24 hours in omeprazole group but only between 4.5 to 5.5 for cimetidine group. 12 pts in the cimetidine group and 2 pts in the omeprazole group rebled. No change in LOS, number of procedures, or mortality (1998)
Management of UGI Bleeding 1
Chronic duodenal ulcer endoscopic control PPI anti-HP antibiotherapy surgery (anterior gastrotomy, duodenotomy)
Gastric ulcer endoscopic control PPI anti-HP antibiotherapy surgery (ulcer excision, , hemigastrectomy,
duodenotomy, vagotomy+pyloroplasty?) Esophageal or gastric varices
endoscopy (rubber banding, intravariceal sclerotherapy)
balloon tamponade (four-port Minnesota tube, Sengstaken-Blakemore tube)
somatostatin, octreotide (synthetic analogue of somatostatin)
vasopressin surgery (transjugular intrahepatic portosystemic shunt
– TIPS, distal splenorenal shunt, central portacaval shunt, Segura procedure)
Management of UGI Bleeding 2
Mallory-Weiss Tears endoscopic coagulation surgery (anterior gastrotomy and direct suture ligation of the tear)
Acute hemorrhagic gastritis H2 receptor blockers PPIs sucralfate antacids antibiotics somatostatin vasopressin surgery (total or near-total gastrectomy)
Neoplasms Benign tumors – wedge excision of the offending lesion Malignant neoplasms
endoscopy surgery (excision)
Esophageal Hiatal Hernia PPI anti-H. pylori antibiotherapy surgery (i.e., laparoscopic Nissen fundoplication)
Management of UGI Bleeding 3
Hemobilia Arteriographic embolization Surgery (hepatic artery ligation or hepatic resection)
Aortoenteric fistula air around the aorta or the aortic graft – emergency exploration
(resection of the graft with extra-abdominal bypass, resection of the graft with in situ graft replacement)
Vascular ectases (vascular dysplasia, angiodysplasia, angiomata, telangiectasia, and arteriovenous malformations)
surgery (excision) Duodenal and jejunal diverticula
surgery (excision) Jejunal ulcer (NSAIDs, infection, gastrinoma)
medications stopping infections treatment surgery (excision of gastrinoma, resection of bleeding segment of the
jejunum)
Lower GI Bleeding
Distal to the ligament of Treitz Causes:
Diverticulosis 60% Angiodysplasia 20% Neoplasia IBD Ischaemic colitis Infective colitis Ano-rectal disease Small intestine coagulopathy Upper GI cause in 10-15%
Management Principles
Treatment & evaluation should be instigated concurrently
Haemodynamic assessment + directed history and examination
PR / proctoscopy essential to evaluate ano-rectum
Initial Management
Large bore IV access + crystaloid resucitation
NGT X-match, coagulation profile, Blood
film & count, routine biochemistry 85% cease spontaneously
Selective Mesenteric Angiography
Once localised can treat bleeding with super selective embolisation
Vasopressin infusion superseeded due to cardiac and ischaemic complications
Management of LGI Bleeding
Endoscopy thermal contact probes laser photocoagulation electrocauterization injection of vasoconstrictors application of metallic clips injection sclerotherapy
Angiographic therapy
Selective Mesenteric Angiography
Super selective embolisation into bleeding vessel (beyond marginal artery)
Excellent control if technically feasible. Time consuming, risk of colonic
infarction (0-20%), rebleeding (10-20%) ?Role of check colonoscopy at 2-3days
Bandi R, Shetty P, Sharma R, Burke T, Burke M, Kastan D. Superselective arterial emboilization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2001; 12: 1399-1405
Colonoscopy 1
Procedure of choice if bleeding has stopped or slowed significantly
Reports of the use of colonoscopy in acute bleeds (+/- cleansing purge)
Only consider in stable patient, abort if severe colitis
Localisation in 70-80%
Jensen D, Machicado G. Diagnosis and treatment of severe hematochezia: the role of urgent colonoscopy after purge. Gastroenterology 1988; 95: 1569-1574
Colonoscopy 2
Heater probe or Argon / Nd:YAG laser can be used to treat angiodysplasia.
Diverticular bleeding can also be treated with endoscopic therapy
Rebleed 10-50%, Perforation <2% Procedure of choice for post polypectomy
bleeding
Jensen D, Machicado G, Jutabha R, Kovacs T. Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage. New Eng J Med; 342(2):78-82
Indications for Surgery
HD unstable despite resuscitation More than 6-8 units PRBC required Ongoing bleeding beyond 72 hours Significant early (<1 week) re-bleed
Surgery
Operative localisation (endoscopy, colotomies, transverse loop colostomy) are notoriously poor
Gastroscopy is essential Treatment of choice is subtotal
colectomy + IRA If localised pre-operatively then
segmental resection. Primary anastomosis is generally safe
References
1. ACS Surgery: Principles and Practice by Douglas W., Md. Wilmore (Editor), Laurence Y., Md. Cheung (Editor), Alden H., Md. Harken (Editor), James W., Md. Holcroft (Editor), Jonathan L., Md. Meakins (Editor), Nathaniel J., Md. Soper (Editor), Douglas W. Wilmore, Laurence Y. Cheung, Alden H. Harken, James W. Holcroft, Jonathan L. Meakins, Nathaniel J. Soper Publisher: WebMD Professional Publishing; 2nd edition (February 1, 2003)
2. Sabiston Textbook of Surgery: the Biological Basis of Modern Surgical Practic. Courtney M. Townsend, Jr., editor-in-chief; associate editors, R. Daniel Beauchamp, B. Mark Evers, Kenneth L. Mattox. W.B. Saunders Company 2001
3. Oxford Textbook of Surgery (3-Volume Set) 2nd edition (January 15, 2000): by Peter J. Morris (Editor), William C. Wood (Editor) By Oxford Press
4. Essentials of Surgery: Scientific Principles and Practice 2nd edition (January 15, 1997): by Lazar J., Md. Greenfield (Editor), Michael W. Mulholland (Editor), Keith T. Oldham (Editor), Gerald B. Zelenock (Editor), Keith D. Lillimoe (Editor), Keit Oldham By Lippincott Williams & Wilkins Publishers
5. Current Surgical Diagnosis and Treatment, 11th Ed 2003: Lawrence W. Way, Gerard M. Doherty By McGraw-Hill/Appleton & Lange
6. Principles of Surgery Seventh Edition Editor-in-Chief Seymour I. Schwartz, M.D. The McGraw-Hill Companies, Inc. 1999
7. Vernava A, Moore B, Longo W, Johnson F. Lower gastrointestinal bleeding 1997. Dis Col Rectum; 40(7): 846-858