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The Clinical Approach to the Most Frequent Acute Conditions in Abdominal Surgery GI Bleeding

The Clinical Approach to the Most Frequent Acute Conditions in Abdominal Surgery GI Bleeding. Adam Janiak. GI Bleeding. Upper GI bleeding Lower GI bleeding. Upper GI Bleeding. Proximal to the ligament of Treitz Causes: peptic ulcer disease (1/2 – 2/3 UGI bleeding)

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The Clinical Approach to the Most Frequent Acute Conditions in Abdominal Surgery GI Bleeding

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  1. The Clinical Approach to the Most Frequent Acute Conditions in Abdominal SurgeryGI Bleeding Adam Janiak

  2. GI Bleeding • Upper GI bleeding • Lower GI bleeding

  3. Upper GI Bleeding • Proximal to the ligament of Treitz • Causes: • peptic ulcer disease (1/2 – 2/3 UGI bleeding) • esophageal varices (10 percent) • hemorrhagic gastritis • gastric varices • nose bleed • Mallory-Weiss tears • reflux esophagitis • gastric neoplasms • hematobilia

  4. Presentations of UGI Bleeding • Severe bleeding • hematemesis25 % • ‘red blood’ hematemesis • ‘coffee ground’ emesis • hematochezia 15 % • hypotension • Gradual bleeding • melena25 %(50 – 100 cc of blood will render stool melenic) • Occult bleeding • positive tests for blood in the stool

  5. Initial Evaluation of UGI Bleeding 1 • Perceived rate of bleeding • Degree of hemodynamic stability • Outpatient basis • hemodynamically stable • no evidence of active bleedingor comorbidities • endoscopic findings favorable • Hospitalization • evidence of serious bleeding

  6. 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

  7. Initial Evaluation of UGI Bleeding 3 • patient stable& no evidence of recent or active hemorrhage – proceedwith the workup. • patient stable& shows evidence of recent or active bleeding – large-bore IV line before workup • patient unstable – immediateresuscitation

  8. 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 –intraoperativediagnosis • laparotomy through an upper midline incision • anterior gastrotomy • pylorus-preserving duodenotomy

  9. 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

  10. Upper GI Endoscopy 1 • almost always reveals the source of UGI bleeding • requires considerable skill • hematemesis –emergencyEGD (within 1 hour of presentation) • melena – urgentEGD • endoscopic control of bleeding sites • injection • thermal coagulation • mechanical occlusion (clip application or variceal banding)

  11. Upper GI Endoscopy 2

  12. Ulcer Appearance and Prognosis

  13. Other Tests • enteroclysis + RTG • Tc tagged red cell scan • arteriography • video capsule endoscopy • intraoperative endoscopy

  14. Enteroclysis

  15. Upper GI Tract Barium RTG

  16. Tc Red Cell Scan

  17. Celiac Arteriography

  18. Video Capsule Endoscopy

  19. 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

  20. 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

  21. 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)

  22. 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)

  23. 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 – wedgeexcision of the offending lesion • Malignant neoplasms • endoscopy • surgery (excision) • Esophageal Hiatal Hernia • PPI • anti-H. pylori antibiotherapy • surgery (i.e., laparoscopic Nissen fundoplication)

  24. 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 – emergencyexploration (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)

  25. 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%

  26. Management Principles • Treatment & evaluation should be instigated concurrently • Haemodynamic assessment + directed history and examination • PR / proctoscopy essential to evaluate ano-rectum

  27. Initial Management • Large bore IV access + crystaloid resucitation • NGT • X-match, coagulation profile, Blood film & count, routine biochemistry • 85% cease spontaneously

  28. Localisation • 99mTc labelled RBC scan • Selective mesenteric angiography • Colonoscopy

  29. Selective Mesenteric Angiography • Once localised can treat bleeding with super selective embolisation • Vasopressin infusion superseeded due to cardiac and ischaemic complications

  30. Management of LGI Bleeding • Endoscopy • thermal contact probes • laser photocoagulation • electrocauterization • injection of vasoconstrictors • application of metallic clips • injection sclerotherapy • Angiographic therapy

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. References • ACS Surgery: Principles and Practiceby 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) • Sabiston Textbook of Surgery: the Biological Basis of Modern Surgical Practic. Courtney M. Townsend, Jr., editor-in-chief; associate editors, R. DanielBeauchamp, B. Mark Evers, Kenneth L. Mattox. W.B. Saunders Company2001 • Oxford Textbook of Surgery (3-Volume Set) 2nd edition (January 15, 2000): by Peter J. Morris (Editor), William C. Wood (Editor) By Oxford Press • 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 • Current Surgical Diagnosis and Treatment, 11th Ed 2003: Lawrence W. Way, Gerard M. Doherty By McGraw-Hill/Appleton & Lange • Principles of SurgerySeventh EditionEditor-in-ChiefSeymour I. Schwartz, M.D.The  McGraw-Hill Companies, Inc. 1999 • Vernava A, Moore B, Longo W, Johnson F. Lower gastrointestinal bleeding 1997. Dis Col Rectum; 40(7): 846-858

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