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.


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


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.


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.


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



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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.



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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.


LABORATORY EXAMINATION

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� CBC

� Electrolytes

� Glucose

� BUN / S.Creatinine

� Coagulation study

� LFT

� Blood group and cross match


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.


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.


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.


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


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 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 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 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 Endoscopy

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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


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.


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


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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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.


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


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


Sclerotherapy

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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


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


Baloon Tamponade

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Baloon Tamponade

1. Linton -Nachlas tube

2. Sengstaken Blackemore

tube

3. Minnesota 4 lumen tube

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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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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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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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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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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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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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� 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 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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Rockall Scoring for rebleeding risk

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�A simplified scoring system based on endoscopic and clinical variables has been developed

Pharmacological Therapy

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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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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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� 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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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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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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1. Hemoclips

2. Banding

3. Endoloop

4. Staples / sutures.

C. Mechanical

Endoscopic Therapy

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Angiographic Therapy

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� 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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� 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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Types of Gastric Ulcer

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Bleeding Gastric Ulcer

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� 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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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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Upper GI Hemorrhage-- Surgical perspective

Health & Medicine

Transcript of Upper GI Hemorrhage-- Surgical perspective