Upper GI Hemorrhage-- Surgical perspective
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Transcript of Upper GI Hemorrhage-- Surgical perspective
Dr.B.SELVARAJ MS;Mch;FICS;
Upper GI Hemorrhage
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‘Surgical Perspective’
Upper GI Hemorrhage
� Dr.B.Selvaraj MS;MCh;FICS;
� Neonatal &Pediatric Surgeon
� Melaka Manipal Medical College
� Melaka- 75150
� Malaysia
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Upper GI Hemorrhage
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Definition :
Bleeding originates from GI tract proximal to Ligament of Treitz.
Presentation :
1. Hemetemesis :
Vomiting of blood Bright red (fresh)
Coffee ground (Old)�Melenemesis
2. Melena: Black tarry foul smelling stools.
3. Hematochezia: Bright red stool per rectum
4. Bleeding through Ryle’s tube (in hospitalized patients)
Upper GI Hemorrhage-Causes
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Non variceal bleeding (80%) :
1.Peptic ulcer disease (30 to 50%)
2.Mallory Weiss tear (15 -20%)
3.Gastritis or duodenitis (10 – 15%).
4.Esophagitis (5 – 10%).
5.A–V malformation (5%).
6.Tumours (2%)
7.Others (5%)
Variceal Bleed ing(20%) :
1.Gastroesophageal varices > 90%.
2.Portal hypertensive gastropathy < 5%.
3.Isolated gastric varices (rare)
Uncommon Causes:
1.Hemobilia
2.Dieulafoy leison
3.Gastric antral vascular ectasia
(GAVE)
4.Aortoenteric fistula
5.Hemosuccus Pancreaticus
Upper GI Hemorrhage-Causes
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Upper GI Hemorrhage- Initial
Goals
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1. Detailed patient assessment with
hemodynamic resuscitation
Identification of co-morbid conditions.
2. Diagnosing the cause of bleeding.
3. Specific measures to achieve hemostasis and to
prevent rebleeding.
Upper GI Hemorrhage- Initial
Management
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Patient assessment Airway, Breathing, Circulation
Patient resuscitation IV access, blood transfusion, labs
Risk assessment Severe , moderate or mild bleeding
Upper Endoscopy
Low risk lesion High risk lesion
Medical Rx Endoscopic Rx Rebleed Surgery
Upper GI Hemorrhage- Initial
Assessment
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1st Step : Assess the severity of bleeding
A: Check vital sign
B: Assess airway and breathing.
C: Assess circulatory status.
Guide resuscitation.
Prognostic information.
Triage of patient.
Vitals sign % Blood loss Severity of
bleed
Normal < 10% Minor
Postural
hypotension
10 - 20 % Moderate
Shock > 20 – 25 % Massive
Upper GI Hemorrhage-
Resuscitation
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Proportional to severity of bleed.
� Inspect and clean airway.
� Check ventilation.
� Supplement oxygen.
� Endotracheal intubation and mechanical ventilation if indicated.
� Fluid therapy.
� Central venous catheter if indicated.
Upper GI Hemorrhage-
Resuscitation
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Elderly > 30%
Young healthy patient > 20 – 25%
Portal hypertension > 27 to 28%
�Use of blood and blood product. A. Whole blood / preferably packed RBC Target of Hematocrit value :
B. FFP / Platelet transfusion
�Vasopressors role �Regular vitals and urine output monitoring.
Upper GI Hemorrhage-
HISTORY AND PHYSICAL EXAMINATION
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1. Assess the severity of bleed.
2. Preliminary assessment of site and cause.
3. Identification of risk factors.
History :
Age of patients :
Elderly patient : Carcinoma.
Young patient : Ulcer disease ,esophagitis ,varices
Upper GI Hemorrhage-
HISTORY AND PHYSICAL EXAMINATION
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� Volume of vomited blood, colour of vomitus, colour of stool
� History of prior GI bleed / Bleed in general.
� History previous disease / intervention.
� Any history of medical illness.
� Ingestion of Asprin / other NSAID.
� History of liver disease .
� History of retching .
� History of nasopharyngeal disease
� History of chronic occult blood loss.
Upper GI Hemorrhage-
HISTORY AND PHYSICAL EXAMINATION
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� Vitals, pallor, icterus , lymphadenopathy , Pedal edema.
� Cutaneous sign e.g. Spider Angiomata , Duputyren’s contracture
� Liver disease: Ascites, Caput medusa
� Malignancy : Acanthosis nigricans, Lymphadenopathy
� Pigmented lip lesion: Peutz - Jegher
� Abdominal tenderness - Peptic ulcer, pancreatitis
� Abdominal mass : Lymphadenopathy, hepatosplenomegaly
� ENT examination.
Upper GI Hemorrhage-
LABORATORY EXAMINATION
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� CBC
� Electrolytes
� Glucose
� BUN / S.Creatinine
� Coagulation study
� LFT
� Blood group and cross match
Upper GI Hemorrhage-
RISK FACTORS
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1. Age > 60 years.
2. Comorbid disease -Renal -Liver
-Respiratory -Cardiac
3. Magnitude of hemorrhage :
Systolic BP < 100 on presentation
Transfusion requirement
4. Persistent / Recurrent hemorrhage
5. Need for surgery.
Upper GI Hemorrhage-
SCORING SYSTEM
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1. Predict risk for rebleeding and mortality.
2. Evaluate the need for ICU admission.
3. To determine need for urgent endoscopy
Bleeding classification :
1. On going bleeding.
2. Systolic BP < 100.
3. PT greater 1.2 times of control.
4. Altered mental status.
5. Unstable comorbid disease.
Upper GI Hemorrhage-
RISK ASSESSMENT
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1. Mild to moderate :
< 60 year (no chronic medical illness).
No signs of hemodynamic instability.
Hematocrit > 30%.
2. Severe :
> 60 year.
Sign and hemodynamic instability.
Acute bleeding.
Drop in hematocrit > 6%.
Severe comorbid disease.
Upper GI Hemorrhage-
Diagnosing the cause for bleeding
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1. History and physical examination.
2. NG tube
3. Esophagogastrodud-enoscopy (EGD)
4. Tagged RBC scan
5. Angiography
Upper GI Hemorrhage-
NG Tube
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� Definite or suspected acute UGI bleeding have a NG tube
� Not contraindicated even in esophageal or gastric varices
� false +ve low – caused by nasogastric trauma.
� Useful to assess the rate of ongoing bleed (not accurate).
� Not provide information about the etiology of bleed.
� Nature of aspirate can serve as a prognostic indicator.
� It also helps in endoscopy by performing gastric lavage.
� Aspirate is (-)ve for blood in upto 25% of patient with UGI
bleed.
Upper GI Hemorrhage-
Upper GI Endoscopy
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Early EGD is performed within 24
hours to maximize efficacy.
� Defines source of bleeding.
� Stratify the risk of rebleed.
� Decrease blood transfusion
requirements, decrease need of
surgery, decrease hospital stay.
� Facilitating operative planning.
� Provide endoscopic therapy.
Upper GI Hemorrhage-
Upper GI Endoscopy
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Accuracy limited by :
1. Active massive bleeding.
2. Abnormal anatomy as a result of previous surgery.
Complication (emergency EGD) :
1. Aspiration.
2. Respiration depression.
3. GI perforation
Timing :
Patient with sign of ongoing bleeding URGENT.
Others – within 24 hours.
Upper GI Hemorrhage-
Upper GI Endoscopy
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� Done when adequate resuscitation achieved
� Best done in endoscopy unit.
� In severely bleeding patient endoscopy should be done with
ET tube in place.
� Insertion of NG tube and stomach lavage is recommended.
� Some endoscopist recommends iv erythromycin prior to
endoscopy
Upper GI Hemorrhage-
Upper GI Endoscopy
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Upper GI Hemorrhage-
Upper GI Endoscopy
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Upper GI Hemorrhage-
Upper GI Endoscopy
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Upper GI Hemorrhage-
Tagged Red Blood cell Scintigraphy
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� Patients with massive hemorrhage in whom a bleeding source is not identified.
� Technetium sulphur colloid or (99Tc) pertechnetate-labeled red blood cells can be used.
� Detect a bleeding as low as 0.1 mL/min
� Highly variable accuracy rates for localizing bleeding, ranging from 24 to 91% (grade B evidence)
� Must have active bleeding
� Radionuclide screening appears to increase the diagnostic yield of arteriography by a factor of 2.4
Upper GI Hemorrhage-
Tagged Red Blood cell Scintigraphy
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� Advantages:
1. Safe
2. Noninvasive
3. Low in cost
� Disadvantages:
1. lack of therapeutic capability and doubt
about its accuracy.
2. Surgical therapy not recommended on
the basis of result of tagged RBC
scintigraphy alone.
Upper GI Hemorrhage-
Angiography
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Rate of atleast 0.5- 1ml/min.
Specificity 100%, sensitivity 30-47%
Advantages :
� No bowel preparation
� Accurate localization of rapidly bleeding lesions
� Immediate hemostasis .
Limited to patient with continued bleeding
Serious complication
� Arterial thrombosis
� Contrast reactions
� Acute renal failure
Upper GI Hemorrhage-
Angiography
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A. Intraarterial vasopressin – Stops bleeding in 20-80% of patients.
Complication :
1. Bowel ischemia.
2. Heart, brain, renal or other and organ ischemia.
3. High chances of rebleeding.
Contraindication :
1. Coronary artery disease.
2. Ischemic bowel disease.
B. Embolic agent : Gelfoam, tissue adhesive beads, clips.
Complication :
1. Rebleeding
2. Ischemia
3. Infarction
4. Abscess formation
Management of Bleeding Varices
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Grading of Esophageal Varices
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Management of Bleeding Varices
Pharmacotherapy
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� Should be started as soon as possible
� Specific agent chosen depends upon availability and physician preference.
� Should be continued upto 5 days to prevent rebleed.
� Best is to use them with endoscopic therapy.
A. Drug that decrease portal blood flow :
1. Non selective β blocker.
2. Vasopressin
3. Somatostatin with its analogue -- Octrotide
B. Drugs that decrease intrahepatic resistant (experimental) :
1. Nitrates
2. α1 adrenergic blocker.
3. Angiotensin receptor blocker.
Management of Bleeding Varices
Endoscopic Therapy
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� Only treatment modality that is widely accepted for
prevention, control and rebleeding of varices.
– Sclerotherapy
– Band ligation
� Sclerotherapy largely supplant by endoscopic band
ligation except when poor visualization precludes
effective band ligation of bleeding varices
Management of Bleeding Varices
Sclerotherapy
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1. Intravariceal injection : Injected directly into varices.
� Solution : Ethanolamine oleate (5%)
Sodium morrhuate 5%.
� Optimal volume : 1 to 2 ml of sclerosants per injection.
� Total volume 10 to 15 ml.
2. Paravariceal injection :
� Injected submucosally adjacent to varices
� Solution 0.5 or 1% polidocanol.
� 0.5 to 1 ml is injected into each site between varices
Management of Bleeding Varices
Sclerotherapy
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Management of Bleeding Varices
Banding (EVBL)
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� Band strangulates the varices, causes thrombosis
� Multiband devices can be used
Advantage
� Easy to perform.
� Fewer complication.
� Fewer session.
Disadvantage
� Gastric fundal varices.
� Banding induced ulcers.
� Use of overtubes causes mucosal tear and esophageal perforation.
Complications of Endoscopic Variceal
Therapy
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A. During procedure :
1. Retrosternal chest pain.
2. Aspiration pneumonia
B. Following procedure :
1. Local ulcer
2. Bleeding
3. Stricture
4. Dysmotility
5. Perforation
6. Mediastinitis
C. Systemic : (Usually with Sclerotherapy)
1. Sepsis
2. Pulmonary embolism
Management of Bleeding Varices
Banding (EVBL)
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� Temporary measure in patients with active, life
threatening hemorrhage refractory to endoscopic and
pharmacological therapy.
� It controls bleeding in 90% cases.
Serious complications :
1. Esophageal perforation.
2. Aspiration pneumonia.
3. Rarely asphyxiation.
� On deflation of balloon rebleeding is seen in high
proportion of cases
Management of Bleeding Varices
Baloon Tamponade
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Management of Bleeding Varices
Baloon Tamponade
1. Linton -Nachlas tube
2. Sengstaken Blackemore
tube
3. Minnesota 4 lumen tube
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Management of Bleeding Varices
TIPS
� Reduces elevated portal pressure.
� Use to treat many complication of portal hypertension.
� Prerequisite (not strict)
1.Platelet count >60000/ µl
2.PT < 1.4
3.Broad spectrum antibiotic coverage
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Management of Bleeding Varices
TIPS
Complication :
1. Procedure related
2. Early post procedure (1 to 30 day)
Major
Minor
3. Late (> 30 days)
� Hemorrhage controlled in > 90% of patient but mortality very high > 60% in 60 days .
� Because of increased mortality and risk of hepatic encephalopathy TIPS can not be recommended as first choice of treatment .
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Management of Bleeding Varices
Surgical Treatment
A. Shunt Surgery
Reduce variceal bleeding and prevent recurrent bleeding.
Indications:
� Failed emergency medical treatment.
� Sites not accessible to sclerotherapy.
� Bleeding following sclerotherapy.
� Isolated portal vein thrombosis.
� Where long term care not be assured.
Surgical Treatment
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Management of Bleeding Varices
Advantages : � High control rate of bleeding and low rebleeding rates.
� One time procedure .
� Improvement in postoperative growth parameters.
Disadvantages : � Postoperative encephalopathy.
� High failure rate of shunts in children (< 10 years).
� Thrombosis.
� Accelerated liver failure .
� Development of effective spontaneous portosystemic shunt with time (48%).
� Failure of liver transplantation.
Surgical Treatment
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Management of Bleeding Varices
B. Non decompressive surgery : � Splenectomy :In patients who bleed from gastric varices secondary to isolated splenic vein thrombosis
� Esophageal transaction and devascularization procedure:(Suguira Procedure)
Indication: � Vessels not available for shunting .
� Extrahepatic portal vein obstruction.
� Preexisting encephalopathy.
� Severely impaired liver function .
� Candidates for liver transplantation.
Limited effect and rebleeding rate is high.
Surgical Treatment
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Management of Bleeding Varices
Suguira Procedures : include esophageal transaction and reanastmosis, truncal vagotomy with either thoracoabdominal or transabdominal portoazygous devascularization of upper half of stomach and lower l/3 of esophagus. Highly effective in controlling active hemorrhage
Gastric Varices
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Management of Bleeding Varices
� Sarin classification :
GOV1 GOV2
IGV1 IGV2
� Endoscopy : preffered
� N butyl– 2 cynoacyrlate
Advantage : Ulcer occur less Risk of rebleed is less
Complication : Bacteremia
Variceal ulceration
Cerebral& Pulmonary
thrombosis
Damage endoscope
Algorithm
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Management of Bleeding Varices
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Management of Bleeding Peptic Ulcer
� Most common specifically
identified cause of UGIB.
� Incidence:duodenal ulcer
twice that of gastric ulcer.
� Ulcer located high on the
lesser curvature of
stomach, posteroinferior
wall of duodenal bulb are
most likely to bleed and
rebleed .
Predisposing Factors
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Bleeding Peptic Ulcer
� Gastric acids .
� H.pylori infection.
� Use of NSAID – Most important predisposing factor.
� CVS and cerebrovascular disease.
� Chronic pulmonary disease, cirrhosis.
� Drugs – Glucocorticoids, bisphosphonate alendronate.
� Ethanol.
� Anticoagulants.
� Hospitalization (poor outcome).
Forrest Classification
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Bleeding Peptic Ulcer
Rockall Scoring for rebleeding risk
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Bleeding Peptic Ulcer
�A simplified scoring system based on endoscopic and clinical variables has been developed
Pharmacological Therapy
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Management of Bleeding Peptic Ulcer
A. Proton pump inhibitor :
� considered additive to that of therapeutic endoscopy.
� Mechanism :
1. Acid pH retard blood cloting and enhances clot dissolution. (it raises gastric pH )
2. Elevating gastric pH facilitates platelet aggregation.
3. Improve ulcer healing in less acidic environment.
� Advantages : Decrease bleeding , rebleeding , surgery, death.
� Side effect : loose stool, abdominal pain, muscle and joint pain, leucopenia, Hepatic dysfunction.On long term -Atrophic gastritis.
Pharmacological Therapy
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Management of Bleeding Peptic Ulcer
B. H2 antagonist :
Disappointing , do not provide maximum acids suppression.
Various agent. Cimetidine, Ranitidine, famotidine, Roxatidine.
Adverse effect : GI effect.CNS effect .Bolus IV injection causes
release of histamine .
C. Nitrates : May play protective role in upper GI hemorrhage.
Under experimental phase.
D. Somatostatin / Octerotide: patients who are severely bleeding and waiting for endoscopy or surgery or other drug therapy is not possible.
E. Antifibrinolytic therapy : Recent metanalysis has shown tranexmic acid therapy will not reduce ulcer rebleeding but appears to reduce mortality.
Endoscopic Therapy
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Management of Bleeding Peptic Ulcer
� Any of the three modality can be used� Injections, Thermal or Mechanical
� No single modality has been shown to be superior than other .
� Operator experience plays a significant role.
� Repeat endoscopy
(a) If there is clinical evidence of active rebleeding (Grade C).
(b) If there are concerns regarding optimal initial endoscopic therapy ( Grade C)
Endoscopic Therapy
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Management of Bleeding Peptic Ulcer
A. Injections :
1. Adrenaline
2. Fibrin glue
3. Human thrombin
4. Butyl 2 cyanoacrylate (0.5% to 1%).
5. Sclerosant.
� Sodium tetradecyl sulphate (1-3%)
� Sodium morrhuate (5%)
� Ethanolamine oleate (5%)
� Absolute alcohol
Endoscopic Therapy
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Management of Bleeding Peptic Ulcer
B. Thermal
1. Heat probe
2. Bicap probe
3. Gold probe
4. Argon plasma
coagulation
5. Laser therapy (Nd-
YAG)
Endoscopic Therapy
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Management of Bleeding Peptic Ulcer
1. Hemoclips
2. Banding
3. Endoloop
4. Staples / sutures.
C. Mechanical
Endoscopic Therapy
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Management of Bleeding Peptic Ulcer
Angiographic Therapy
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Management of Bleeding Peptic Ulcer
� Indication : Severe persistent bleeding with endoscopy unsuccessful or unavailable and surgery too risky.
� Superselective angiogaphic approach is used
A. Intraarterial vasopressin– Stop bleeding in 20-80% of patients.
Contraindications :
• Coronary artery disease.
• Ischemic bowel disease.
B. Embolic agent : Gelfoam, tissue adhesive beads, clips.
Surgery
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Management of Bleeding Peptic Ulcer
� Bleeding is severe and uncontrolled in 5% to 10%.
� Mortality rate of approximately 25% as compared to 10% (non operated).
� Indication :
– Hemodynamic instability despite vigorous resuscitation (>6 units transfusion).
– Failure of endoscopic techniques.
– Recurrent hemorrhage after initial stabilization.
– Shock associated with recurrent hemorrhage.
– Continued slow bleeding with a transfusion requirement exceeding 3 units/day.
Surgery
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Management of Bleeding Peptic Ulcer
Types of Gastric Ulcer
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Management of Bleeding Peptic Ulcer
Bleeding Gastric Ulcer
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Management of Bleeding Peptic Ulcer
� In type I ulcers, partial gastrectomy /ulcer excised and closed/
ulcer is biopsied and oversewen .
� Type II and type III bleeding ulcers. Excision with primary
closure / a distal gastrectomy /gastric ulcer excision with a
vagotomy and pyloroplasty is used . Postoperatively patients
should have H. pylori infection eradication and avoid use of
NSAIDs.
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Long term Management of Bleeding
Peptic Ulcer
� Gastric ulcers repeat endoscopy
approximately six weeks after
discharge . Proton pump
inhibitor continued until that
point (Grade C).
� Endoscopic confirmation of
duodenal ulcer healing
following H pylori eradication is
probably not necessary although
the subgroup needing to
continue NSAID while receiving
ulcer healing therapy probably
should be re-endoscopied
(Grade C).
Algorithm
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Management of Bleeding Peptic Ulcer
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Dieulafoy Lesion
� Definition
� Location
� Bleeding is massive and recurrent
� Endoscopic options
Coagulative therapy�APC Hemoclips
Banding
� Surgery:
1. Gastrotomy with sewing of
bleeding source.
2. Partial gastrectomy if bleeding is not identified
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Mallory Weiss Tear
� Mucosal or submucosal
tear that occur near GE
junction
� Diagnosis based upon
history & endoscopy .
� Important to perform a
retroflexion maneuver.
� Most tear occur along
lesser curvature
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Mallory Weiss Tear
� Supportive therapy in 90%.
� Endoscopy therapy with injection or electrocoagulation
� Angiographic embolisation
� Surgery – high gastrotomy and suturing of mucosal tear is
indicated.
� Recurrent bleeding is uncommon.
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Gastric Erosions
� Gastritis affect gastric mucosa
not muscularis mucosa , major
blood vessel are not injured.
� Gastropathy often erosive
� Superficial gastric erosion
developed in following
condition
1. Stress related
2. NSAID induced.
3. Consumption of ethanol
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Gastric Erosions
Who develops significant bleed can be managed by –
1. Acid suppressive therapy :
Most often successful in controlling bleed
2. Endoscopic therapy
3. Angiography -Octerotide / vasopressin in left gastric artery
Embolization
4. Surgery – Rarely indicated.
Vagotomy and pyloroplasty with over sewing of hemorrhage.
Near total gastrectomy
Mortality is high 60%
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Esophagitis
� Common cause
� Causes occult blood loss more
commonly
� Causes :
GERD
Infectious
Medication
Crohn’s disease
Radiation.
� Treatment :
Therapy directed against cause
Acid suppressive therapy.
Endoscopic control (Electrocoagualtion or heat probe)
Operation is seldom necessary
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Duodenitis
� Very rare cause of acute bleed.
� Risk factors for severe erosive duodenitis are similar to those
patient with bleeding peptic ulcer.
(NSAID, H.pylori, anticoagulation therapy).
� Bleeding is rarely usually self limited and rarely required
intervention.
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Malignancy
More often associated with
occult, self limited
asymptomatic bleeding.
� Most common advanced
gastric adenocarcinoma.
� Endoscopic therapy often
successful in controlling
hemorrhage but rebleeding
rate is high.
� Therefore surgical treatment
is important
Gastric Antral Vascular Ectasia (GAVE)
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� Middle age, elderly female
with
1. Achlorhydria
2. Atrophic gastritis
3. Cirrhosis.
� Characterised by aggregates of ecstatic vessels that appears red spot of gastric mucosa.
� Arranged in linear pattern in the antrum of stomach. “Watermelon Appearance”
� Endoscopic therapy
� If fail antrectomy is done
Aortoenteric Fistula
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� Primary aortoduodenal fistula are rare ,previous abdominal aortic repair , inflammatory or infectious aortitis.
� Mechanism : Development of pseudoaneurysm. Subsequent fistulalization into overlying duodenum.
� Hemorrhage massive and fatal ,Sentinel bleed.
� Bleeding in distal duodenum 3rd or 4th part is diagnostic.
� CT Scan with iv contrast : Air around graft , Possible pseudoaneurysm , Rarely IV contrast in duodenal lumen.
� Treatment : Ligation of aorta proximal to the graft, removal of the infected prosthesis and extra anatomical bypass.
Hemobilia
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It is typically associated with trauma, recent instrumentation
of the biliary tree, or hepatic neoplasms.
� Presents with hemorrhage, right upper quadrant pain, and
jaundice � Quenk’s Triad
� Endoscopy can be helpful by demonstrating blood at the
ampulla.
� Angiography is diagnostic procedure of choice,
angiographic embolization is preferred treatment
Hemosuccus Pancreaticus
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� Caused by erosion of pancreatic pseudocyst into the
splenic artery.
� Patients with abdominal pain, blood loss and a past
history of pancreatitis.
� Angiography is diagnostic and permits embolization,
which is often therapeutic.
� In cases that are amenable to a distal pancreatectomy,
often results in cure.
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