Transcript Upper Gastrointestinal Hemorrhage

Acute Gastrointestinal
Hemorrhage
Sirikan Yamada, M.D., F.R.C.S.T
Assistant Professor
Department of Surgery
Faculty of Medicine, CMU
Chiang Mai, Thailand
“Learning without thinking is useless.
Thinking without learning is dangerous.”
- Confucius
Acute Gastrointestinal Hemorrhage
Definition and Terminology
I> Upper gastrointestinal hemorrhage
(UGIH)
: Bleeding upon the ligament of treitz
•Hematemesis : vomiting for fresh blood
shown active/ massive bleeding
Acute Gastrointestinal Hemorrhage
Definition and Terminology (cont)
•Coffee ground: blood+gastric secretion
shown resent subside UGIH
•Melena: Hb+acid= acid hematin, since 50cc
of blood 1000cc of blood caused melena
persist For 5-7 days, and occult blood can be
positive for 21 days
Acute Gastrointestinal Hemorrhage
II> Lower gastrointestinal hemorrhage
(LGIH): bleeding below ligament of Treitz
Hematochezia: means fresh blood, clot,
or current jelly stool
Divisions of the stomach (From Zuidema G: Shackelford’s
Surgery of the Alimentary Tract, 4th ed. Philadelphia,
WB Saunders, 1995.)
Upper gastrointestinal
hemorrhage(UGIH)
*** Guideline for approach and
management
non-variceal bleeding
- Related Surgical Anatomy and
pathophysiology of Stomach and
Duodenum
- Group of diseases caused UGIH and
specific consideration
- Endoscopic and surgical management
for UGIH
Upper gastrointestinal hemorrhage(UGIH)
variceal bleeding
- Cirrhosis and portal hypertension
- Endoscopic diagnosis and
management
- Surgical management
Lower gastrointestinal hemorrhage
( LGIH)
- Relate Surgical Anatomy of small and
large intestine
- Guideline for approach and treatment
- Group of diseases cause LGIH and
specific consideration
- Historical background of
investigation for localization and
surgical management for LGIH
PERIOD I …
Why we have to learn …..
Over all mortality rate is still high
in upper GI hemorrhage,
about 5-8%
Dudnick R, Martin P, Friedman LS; management of
bleeding ulcer. Med Clin North Am 75:948,1991
Blood supply to the stomach and duodenum with anatomical relationships to the spleen
and pancreas. The stomach is reflected cephalad. (From Zuidema G: Shackelford’s
Surgery of the Alimentary Tract, 4th ed. Philadelphia, WB Saunders, 1995.)
NERVE SUPPY TO THE STOMACH
GASTRIC
GLAND
Risk Factor for Peptic Ulcer Hemorrhage
Aspirin (ASA) : since 1899
Non-steroidal antiinflammatory drug ( N-SAID) :
has both Cyclooxygenase-1 and 2:
COX - 1(house keeping enzyme) & COX 2( Coenzyme)
Selective COX- 2 inhibitor: 1999
EX: Clelcoxib, Rofecoxib
COX theory
 ASA – inhibit COX- 1, decrease Thromboxane&
decrease prostaglandin caused of lost of protection
for gastric mucosa, and decrease hemostasis
 N-SAID- inhibits both COX-1 and COX-2 :results
like in ASA user. Increase risk of complication in PU
patients =6.1 (relative risk) and in recent GI bleeding
patients= 13.5 (relative risk)
 Selective COX-2 inhibitor: results more protection
for gastric mucosal barrier, and hemostasis
Acute Gastrointestinal Hemorrhage
 IDENTIFICATION SOURCE OF BLEEDING
AND SPECIFIC THERAPY
 RESUSCITATION
and STABILIZATION
 INTENSIVE MONITORING
 INITIAL ASSESSMENT
** Initial
evaluation and treatment of patients
with acute gastrointestinal hemorrhage
UPPER GI HEMORRHAGE
How should surgeons deal with and
step up this complicated problem ?
Initial Assessment
Initial Resuscitation
Critical care and monitoring
Definite diagnosis and management
Evidence based critical care, Paul Ellis Marick , 2001
I. Initial Assessment
A: General assessment and Scoring to
categorize the patients
- Active or ongoing/ massive/ continue/ or
intermittent bleeding
B:Hx and PE (Cirrhotic patient or Non cirrhotic
patient )
C:NG tube should be inserted to confirm the
level of bleeding
A. General Assessment
 Hemodynamic assessment : BP, pulse, postural
changes, peripheral perfusion
 The presence of co morbid diseases
 Estimation of blood loss by nasogastric tube
intubation and hemodynamic response to fluid
challenge
** remarked that
- to use 2 L of crystalloid to stabilize v/s , blood
loss is about 15-30%
- If BP raises but fall again, blood loss is about
30-40%
- If BP continues to fall, blood loss is more than
40%
Category of Hypovolemic Shock
Class I:Impending (< 10% of blood volumn
loss)
no symptom,pulse > 90-100 , BP normal
Class II: mild (10-20% of blood volumn loss)
fainting, pallor, cool skin, BP drop, pulse>120
Class III:modurate(20-30% of blood volumn
loss): urine output -oliguria
Class IV: severe ( >40% of blood volumn loss)
may caused unconcious and cardiac arrest
Category and scoring of patients
To evaluate and predict further ulcer
hemorrhage
To select the method of management
“ It is dictated by the rate of bleeding”
Clinical bleeding
1.Trace heme-positive stools and without severe
anemia ( OPD) of cases
2.Visible blood, coffee ground, melena ( IPD/
further evaluation)
1+ 2 = 80 % of cases
Fleischer D, et al Gastroenterology, 1983
3.Persistent or massive bleeding / referred due to
rebleeding with hemodynamic instability (ICU)
** Massive/ ongoing bleeding is defined as loss of
> 30% of estimated blood volume or bleeding
required blood transfusion > 6 U/ 24 hours
Scoring to categorize the patients
 Forrest classification
severe, moderate, mild
Lancet 1974
 Rockall Risk Scoring
Gut 1996
 New Scoring System by Blatchford
Lancet 2000
 Modified Rockall Score for both Non-variceal and
Variceal bleeding
AJG 2002
Rockall Scoring
 Age
 Shock
 Co morbid disease ( cancer diseases)
 Endoscopic diagnosis
 Stigmata of recent hemorrhage
Pre-endoscope score 0-7
Post –op endoscope score 0-11
* this scoring system is good to predict for the
mortality rate much than rebleeding
0-3 : mortality rate = 0 – 11%
4-7 : mortality rate = 24- 27%
 > 8 : motality rate = > 40%
Rockall TA et al GUT 1996; 38: 316-21
New Scoring System by Blatchford
Admission Hb
BUN
Pulse
Systolic BP
Fainting or melena as chief complaint
Liver disease or cardiac disease
• to predict the need for clinical interventions
• But it is in only one study
High Risk ~Criteria
 Host Factors
- Age >60yr
- Co-morbid conditions e.g. renal failure, cirrhosis,
cardiovascular disease, COPD
- Hemodynamic instability; mod to severe shock
- Coagulopathy include drug-related
 Bleeding character ; Active continue red blood
from NG after irriagtion and red blood per
rectum
 Patient course; massive blood transfution> 4-6
units to maintain Hb in 24 hr , re-bleeding in 72
hr , return to have hemodynamic instability
2004 Concensus for Clinical Practice Guideline for the Management of
Upper GI bleeding;
สมาคมโรคทางเดินอาหารแห่งประเทศไทย
I. Initial Assessment
A: General assessment and Scoring to
categorize the patients
- Active or ongoing/ massive/ continue/ or
intermittent bleeding
B: Hx and PE (Cirrhotic patient or Non
cirrhotic patient )
C: NG tube should be inserted to confirm the
level of bleeding
B. Take Hx and PE (Cirrhotic patient or
Non cirrhotic patient )
- History taking of previous medication and
underlying diseases/ anticoagulant usage.
- Esophageal varices is more suspicious
for 60% - 80% in severe upper GI bleeding
with history of advanced liver disease or a
history of previous variceal bleeding.
Prediction of UGI bleeding etiology

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
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
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Incidence(%)
Duodenal ulcer
24.3
Gastric erosions
23.4
Gastric ulcer
21.3
Esophageal varices
10.3----------20% (in cirrhosis)
Malorry-Weiss tear
7.2
Esophagitis
6.3
Duodenitis
5.8
Neoplasm
2.9
Marginal( stomal) ulcer
1.8
Esophageal ulcer
1.7
Miscellaneous
6.8
Silverstein FE, Gilbert DA, Tadeseo FJ, et al,
The national ASGE Survey on upper gastrointestinal bleeding
Gastrointestinal Endoscopy, 1981
I. Initial Assessment
A: General assessment and Scoring to
categorize the patients
- Active or ongoing/ massive/ continue/ or
intermittent bleeding
B: Hx and PE (Cirrhotic patient or Non cirrhotic
patient )
C: NG tube should be inserted to confirm the
level of bleeding
C. NG tube placement
Should perform in all UGI hemorrhage
to confirmation that it is the upper GI
bleeding , monitoring of bleeding and ,
decompressed the stomach
No report that it may potentiate bleeding in
case of esophageal varices, just careful in
patients who had severe coagulopathy.
UGI


LGI
 Melena
 Hematemasis or
coffee ground
 Maroon stool

*
 Red stool
 **
*
 Guaiac test


( can positive more 2 weeks after bleeding stopped)
* Bile was seen via NG tube
** Massive bleeding
Necessary Laboratories
CBC,plt
BS, BUN, Cr, electrolyte
PT, PTT, bleeding time
LFT
G/M
EKG
CxR
II. Initial Resuscitation
How to do for good resuscitation?
When will we give blood transfusion ?
 Which medication will be used?
 Large- bore intravenous lines or central lines
 NG tube aspiration (by hand) to decompress clot
in stomach
 Volume expansion with colloid or crystalloid
 Transfusion of blood immediately if patient has
hemodynamically unstable
* Blood products are the most efficient
volume expanders
** It take about 72 hours for Hct to reach its
nadir; therefore, a normal or moderate low Hct
does not exclude significant bleeding
*** Conversely, minimally falling of Hct also
represent fluid disequilibrium much rather than
continued bleeding
 If patients have coagulopathy, they should be
corrected.
- PTT prolong > 1.5 times
- Platelet < 50,000/ mm3
- FFP should be given after 6 unit of PRC and plt
should add after 10 unit of PRC
 Monitoring V/S, urine out put /hour
 Airway protection in those who have alteration of
consciousness or endotracheal intubations may
facilitate to investigate and give treatment in these
patients
 Recommendation for empiric
Acid- suppression therapy
Traditionally treated, even before the cause is
determined, with acid suppression therapy. Medications
are extremely safe, although the efficacy of this practice
has not been proven conclusively.
Kupfer, et al Gastroenterol Clin of North Amer, 2000
I.V. Proton pump inhibitor is more effective than
I.V. H 2 blocker in increasing intragastric pH
Vasopressin should not be used due to its systemic side
effect
High dose omeprazole significantly
reduces the frequency of further bleeding
and of surgery in patients with bleeding
ulcer.
dosage 40 mg i.v. every 12 hrs. for 5 days
Saltzman JR, N Engl J Med, 1997
NEW GENERATION PPI
-
Lanzoplazole
Pantoprazole
Rabeprazole
Esomeprazole
SOMATOSTATIN
Somatostatin / Octreotide infusion
- In massive UGIH with Hx of advance
liver disease is recommended
PROSTAGLANDIN ANALOQUE
- Cytoprotective agent
Somatostatin causes
- Splanchnic vasocostriction
- Reduces Azygos venous blood flow
- Reduces portal colatteral circulation and
decreases portal pressure
Octreotide (Somatostatin analoque)
50 microgram i.v.bolus then
50 microgram/ hr for infusion rate for 5
days
it can be discontinued without tapering.
III. Critical care and monitoring
ICU is needed, when?
- Massive/ continue or on going bleeding
with or without coagulopathy
- High Rockall scoring patients ( high risk
of morbidity & mortality due to continue
or rebleeding
- Severe co-morbid disease
IV. Definite diagnosis and management
Esophagogastroduodenoscope
( EGD for Dx and Rx)
Technique of operative intervention
Endoscogastroduodenoscope
( EGD for Dx and Rx)
Indication and Timing
- In high score patients ( > 3)
- Shock Category II, III
- Promptly as a double set up in active /massive
bleeding
- Under specialist to perform endoscopic
therapy for hemostasis or localized potential
angiographic or surgical therapy
* Initial diagnostic procedure of choice
should be performed in first 6- 24 hour
after onset of bleeding
Precaution and contraindication
 Absolute contraindication
- GI perforation
- Acute uncontrolled unstable angina
- Severe untreated coagulopathy
- uncontrolled respiratory decompensation
- unexperience endoscopist and patient
agitation and uncooperation
* Intraoperative endoscopy ( on ET-tube
and G/A ) in selected cases or shift the
intervention to surgery or conservative only
General Complications of EGD
GI perforation
Sepsis
Pulmonary aspiration
Respiratory failure
Induce bleeding
Ventricular tachycardia
Myocardial infarction
Death
Prediction of further ulcer hemorrhage
 The most important endoscopic predictor of
persistent or recurrent bleeding is active bleeding(
arterial spurting or oozing) at the time of endoscopy
 The rate of rebleeding is approximately
3 % in the low risk group
25% in the high risk group
 Number of blood transfusion units
> 5 units = 57% needing Surgery, mortality = 43%
Adverse Prognostic Factors in UGIH
Endoscopic criteria for endoscopic intervention
because of high rate of continue or re-bleeding
Stigmata of recent hemorrhage: Forrest classification I,II
 Active bleeding lesion, oozing
 Visible vessel, Adherent clot
Ulcer location
 Posterior duodenal bulb
 Higher lessor gastric curvature, High lying ulcer
Ulcer size and character
 Large and hard edge
Forrest’s Endscopic finding Classification
IA : Active or Spurting
IB : Oozing ulcer
IIA: Non-bleeding visible vessel
IIB: Adherent clot
III : other unspecsified
Endoscopic Intervention For PU bleeding
1) Thermal Techniques ; monopolar/bipolar/heater
probe/laser photo coagulation
2) Injection Methods; 3.6% hypertonic saline+1:20,000
adrenalin 9-12 cc or 1:10,000 10 cc via 23-25 gauge
needles. 0.5 cc each point
3) Topical Agents; cyanoacrylate tissue glues/
microcrystalline collagen hemostat : * good for diffuse
gastric mucosal lesions or adjunct to other modalities
4) Mechanical methods; Hemoclips (1.5mm)/ balloon
tamponad
Sukawa, et al, Surg Clin of North Amer, 1992
Post combind adrenalin injection
And Heat probe coagulation in acute
GU bleeding
Post injection + Heater probe coagulation
in active DU bleeding
Follow up EGD of DU bleeding 1 month
Dieulafoy’s lesion
: Therapeutic Hemoclip via EGD
Complication
Perforation ; 1-3 %
Necrosis on high dose epinephrine
Induce acute and delayed hemorrhage
5-30% in visible vv. those treated by
thermal therapy or injection therapy
* most common is cardiopulmonary in nature
or related to sedation given
** Prophylaxis antibiotic should be applied
Endoscopic Intervention
For Esophageal varices :
1) Endoscopic band ligation combind
2) Endoscopic sclerosing therapy: 1% Ethoxyscleral
solution 0.5-1cc /point
3) Combined
Ballon Tamponad for temporary control after fail
endoscopic intervetion control
( Senstaken Blakemore tube preparation)
INTRAVARICEAL
INJECTION
( underfluoroscope
and venogram)
PARAVARICEAL
INJECTION
ENDOSCOPIC
MUCOSAL
VARICEAL
BAND LIGATION
SB- tube
Complication
Prophylaxis antibiotics cover gram negative
bacteria such as ciprofoxacin, levofloxacin,
ceftacidime, amoxicillin-culvulanic
acid,and aztreonam are appropriate
choices
TIPS( Transcutaneous-jugular
intrahepatic portosystemic shunts)
Non-operative shunt
Use in stage of cirrhosis with liver failure
In non-randomize trial : Less effective to
stop GI bleeding than operative shunt, but
less invasive.
Technique need radiointervention
( described by Zemel G, Katzen B T, Becker G J, et al
TIPS, JAMA, 266:390,1991 )
Topic of interest…..
Video capsule Endoscopy
Intraoperative endoscopy
Rare causes of upper gastrointestinal
hemorrhage from an obscure source;
small intestine above ligament of treiz that
EGD could not exam, new scope was
developed
Gastric Diverticulum
Post operative EGD to follow up
For non-definite surgical procedure cases
; after 2 week post operation (in Japan)
To check for malignant potential and
adjunct medical treatment including
H.pylori eradication in some case
* There is a report of unnecessary
management to eradicate H.pylori at the
time of hemorrhage occurrence.
Type of GASTRIC ULCER
GU ( Johnston’s criteria)
Acute or Chronic
Type I: at Lessor curvature
Type II: GU anywhere with DU
Type III: at Prepylorus( prepyloric ulcer)
Type IV: in 5 CM below EG junction
(high lying GU)
Type V - ?
DUODENAL ULCER (DU)
Acute or Chronic
Post bulbar
Kissing ulcer
Aortoenteric fistula
Operative intervention
To stop bleeding by suture in emergency
situation or failure bleeding control by
endoscopic intervention 1-2 times.
To definite treatment for the cause of
bleeding
High risk patient, massive and no time, no
blood( rare blood group AB, Rh negative ,
no skillful endoscopist)
Operative Finding
Do not forget to palpate and look for the
scar at stomach and duodenum both
anterior and posterior wall.
Technicques for suture and tissue
handling
Do not forget to pack the spleen before
mobilization of stomach
Hanging suture should be used
Atraumatic non-absorable suture should
be used
Babcock preferred to use for temporary
handling stomach incision edge
Incision should start at anterior stomach
wall longitudinally or at place that EGD
suspected the cause of bleeding.
Technicques for suture and tissue
handling
 Suture bleeding point by Transfixing U stitch
 it should be performed in acute massive DU
hemorrhage
 For the difficult large duodenal ulcer and chronic
ulcer, alternative surgical procedures may be
added depend on condition of patient
- Ulcerectomy
- TV with drainage procedure ( various type of
pyloroplasty, gastrojejunostomy)
** selection for complete diverticulization
Technicques for suture and tissue
handling
 Difficult chronic GU ; need tissue ?
> 10% of GU > 1 cm are malignant ulcer
Chua CL and Jeyaraj PR, Am J Surg; 1992
Difficult type
- posterior wall ulcer; ulcerectomy with or
without leaving the ulcer to capsule of
pancrease
- high lying GU type IV ( Johnston’s type)
Acid Reducing and Drainage Precedure
 VAGOTOMY : reduce acid secretion in cephalic
phase
- TV ; resect vagus n. both ant. and post. trunk
And need to do drainage procedure, always
- SV ; resect ant. Vagus n. and post. N.of
Latajet ( vagus n. after separation of celiac and
hepatic branch). Need to do drainage procedue
- HSV ; resect only branch of Latajet and
preserve branch at Craw foot to preserve
function of pylorus
 ANTRACTOMY : reduce G-cell
( Billroth I, or Billroth II)
TV
HSV
ANTRECTOMY
BILLROTH I
BILLROTH I
WITH TV
BILLROTH II
Operative Procedure for chronic GU and DU
 GU Type I
; Antrectomy include ulcer or
ulcer excision
 GU Type II ; Ulcer excision& TV &
pyloroplasty or highly selective vagotomy( HSV)
 GU Type III and DU ; 3 options
1) Suture bleeding point & TV/SV with pyloroplasty
2) Suture bleeding point & HSV
3) Antrectomy with TV or SV
In GI hemorrhage – To stop bleeding is the main aim ****
Surgical tecniques for highlying GU( type IV)
 Most aggressive distal gastrectomy including portion of ulcer
at esophageal wall with roux-en –Y esophagogastrojejunostomy;
“ Csendes procedure”
Am J Surg; 1978
 Antrectomy only with leaving the ulcer in place due to it close
to EG junction;
“ Kelling- Made- lener procedure” , Maingot ;1997
Greenfield; 1992
 For 2-5 cm ulcer at lessor curvature from EG junction; distal gastric
resection with a vertical extension( tonque) to include the lesser
curvature with end-to-end gastroduodenostomy.
“ Pauchet procedure”
Shackelford’s; 1991
 Wedge of anterior and posterior gastric wall at lessor curvature
to include the ulcer, with ligation of left gastric vessels close to
stomach wall ; “ Shoe- maker”
LOCAL PostOp
COMPLICATION
 Re-bleeding
 Mediastinitis
 Leakage
 Post
gastrectomy
syndrome
Emergency Surgery for EV Bleeding
PURPOSE
 Indirect control of bleeding site

Do not change the mortality after bleeding EV
in cirrhotic patient
1) Emergency Total or nonselective- Shunt
Operation: Portocaval shunt is the procedure of
choice
2) Non-Shunt Operation: Sugiura’s( Esophageal
transection with devascularizatoion) , Hassab’s
operation(Total devascularization)
Selective shunt ( distal splenorenal)
Gastric Varices
Primary
Lessor curvature : common- resolute after
Endoscopic intervention for RX of EV
Greater curvature: Less common
Secondary
Isolated Gastric Varices: Fundus, due to
splenic vein thrombosis treated by
SPLENECTOMY
PERIOD II
Lower gastrointestinal hemorrhage
( LGIH)
- Relate Surgical Anatomy of small and
large intestine
- Guideline for approach and treatment
- Group of diseases cause LGIH and
specific consideration
- Historical background of
investigation for localization and
surgical management for LGIH
Approach to Hematochezia
 Massive Ongoing Bleeding
10-20% of patients with massive bleeding
Major Self Limited Bleeding
80-90% of patients with massive bleeding
Minor Self Limited Bleeding
Diagnosis investigation for LGIH
 Nuclear Scintigraphy
- Sulfur colloid scan
- Technetium 99-m labeled RBC scan
 Selective visceral Angiography
 Colonoscope
 Barium Enema
 Ix for small intestine bleeding
Causes and Treatment of Lower GI
Hemorrhage
 Colonic Diverticular Disease
 Arteriovenous Malformation (AVM)
 Inflammatory Bowel Disease
 Radiation Injury to Small and Large Bowel
 Tumor of Colon and Rectum
 Intussusception
 Ishemic Colitis
 Colon and Anorectal Varices
 Meckel’s and other small intestinal diverticula
Baron ligation
Operative Intervention
Exploratory Laparotomy
Looking for the cause of bleeding
as the information of localization
preoperatively
Perform small bowel resection or colonic
resection if localization
Incase of none localization and negative
intraoperative localization, right
hemicolectomy may be performed