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Upper GI Hemorrhage-- Surgical perspective
Dr.B.SELVARAJ MS;Mch;FICS; Upper GI Hemorrhage M M M C ‘Surgical Perspective’
Upper GI Hemorrhage Dr.B.Selvaraj MS;MCh;FICS; Neonatal &Pediatric Surgeon Melaka Manipal Medical College Melaka- 75150 Malaysia M M M C
Upper GI Hemorrhage M M M C 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 M M M C 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 M M M C
Upper GI Hemorrhage- Initial Goals M M M C 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 M M M C 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 M M M C 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 M M M C 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 M M M C 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 M M M C 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 M M M C 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 M M M C 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 M M M C CBC Electrolytes Glucose BUN / S.Creatinine Coagulation study LFT Blood group and cross match
Upper GI Hemorrhage- RISK FACTORS M M M C 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 M M M C 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 M M M C 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 S V M C 1. History and physical examination. 2. NG tube 3. Esophagogastrodud- enoscopy (EGD) 4. Tagged RBC scan 5. Angiography
Upper GI Hemorrhage- NG Tube S V M C 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 S V M C 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 S V M C 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 M M M C 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 M M M C
Upper GI Hemorrhage- Upper GI Endoscopy M M M C
Upper GI Hemorrhage- Upper GI Endoscopy M M M C
Upper GI Hemorrhage- Tagged Red Blood cell Scintigraphy M M M C 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 M M M C 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 M M M C 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 M M M C 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 M M M C
Grading of Esophageal Varices M M M C
Management of Bleeding Varices Pharmacotherapy M M M C 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 M M M C 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 M M M C 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 M M M C
Management of Bleeding Varices Banding (EVBL) M M M C 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 M M M C 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) M M M C
M M M C 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
M M M C Management of Bleeding Varices Baloon Tamponade 1. Linton -Nachlas tube 2. Sengstaken Blackemore tube 3. Minnesota 4 lumen tube
M M M C 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
M M M C 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 .
M M M C 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 M M M C 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 M M M C 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 M M M C 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 M M M C 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 M M M C Management of Bleeding Varices
M M M C 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 M M M C 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 M M M C Bleeding Peptic Ulcer
Rockall Scoring for rebleeding risk M M M C Bleeding Peptic Ulcer A simplified scoring system based on endoscopic and clinical variables has been developed
Pharmacological Therapy M M M C 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 M M M C 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 M M M C 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 M M M C 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 M M M C 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 M M M C Management of Bleeding Peptic Ulcer 1. Hemoclips 2. Banding 3. Endoloop 4. Staples / sutures. C. Mechanical
Endoscopic Therapy M M M C Management of Bleeding Peptic Ulcer
Angiographic Therapy M M M C 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 M M M C 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 M M M C Management of Bleeding Peptic Ulcer
Types of Gastric Ulcer M M M C Management of Bleeding Peptic Ulcer
Bleeding Gastric Ulcer M M M C 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.
M M M C 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 M M M C Management of Bleeding Peptic Ulcer
M M M C 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
M M M C 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
M M M C 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.
M M M C 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
M M M C 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%
M M M C 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
M M M C 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.
M M M C 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) M M M C 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 M M M C 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 M M M C 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 M M M C 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.
M M M C
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