The Clinical Approach to the Most Frequent Acute Conditions in

Abdominal SurgeryGI Bleeding

Adam Janiak

GI Bleeding

Upper GI bleeding

Lower GI bleeding

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)

Upper GI Endoscopy 2

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

Enteroclysis

Upper GI Tract Barium RTG

Tc Red Cell Scan

Celiac Arteriography

Video Capsule 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

Localisation

99mTc labelled RBC scan Selective mesenteric angiography Colonoscopy

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

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