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Surgery 6th year, Tutorial (Dr. AbdulWahid)
 

Surgery 6th year, Tutorial (Dr. AbdulWahid)

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Dec. 7th, 2011

Dec. 7th, 2011

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  • Watermelon stomach = Gastric antral vascular ectasia

Surgery 6th year, Tutorial (Dr. AbdulWahid) Surgery 6th year, Tutorial (Dr. AbdulWahid) Presentation Transcript

  • GI Hemorrhage ABDWAHID M SALIS, M.D
  • Incidence
    • 1-2% of all hospital admissions
        • Most common diagnosis of new ICU admits
    • 5-12% mortality
        • 40% for recurrent bleeders
    • 85% stop sponateously
        • Those with massive bleeding need urgent intervention
        • Only 5-10% need operative intervention after endoscopic interventions
  • Site
    • Upper
        • Esophageal
        • Stomach
        • Doudenum
        • Hepatic
        • Pancreatic
    • Lower
        • Small bowel
        • Colon
        • Anus
  •  
  • Gastric varices
  • Gastric varices Esophageal Varices
  • Gastric varices Bleeding ulcers Esophageal Varices
  •  
  • Gastritis
  • Gastritis Dieulafoy’s lesion
  •  
  • Mallory-weiss
  •  
  •  
  •  
  • Watermelon stomach
  • Upper GI hemorrhage
    • Etiology
        • Peptic ulcer disease - 50%
        • Varices – 10-20%
        • Gastritis – 10-25%
        • Mallory-weiss – 8-10%
        • Esophagitis – 3-5%
        • Malignancy – 3%
        • Dieulafoy’s lesion – 1-3%
        • Watermelon stomach – 1-2%
  • Gastrointestinal Bleeding
    • Hematemesis - Vomiting of blood from the oropharynx to the ligament of Treitz.
    • Gross Blood And Blood Clots: rapid bleeding
    • Coffee-ground Emesis : chronic bleeding.
    • Melena- Passage of black and tarry stool caused by digested blood.
    • Hematochezia- Passage of maroon to red blood and blood clots.
  • Melena
    • usually the result of severe upper GI bleeding.
    • without hematemesis :severe bleeding distal to the ligament of Treitz.
    • 50-60 mL of blood in the GI tract produces melena
    • after a 2 unit bleed : Melena can persist from 5- 7 days and stools can remain occult positive up to 3 weeks.
  • Nose bleeds-
    • Rarely the cause of major bleeding.
  • Esophagitis
    • Hiatus hernia Significant bleeding in para- esophageal hernias.
    • Reflux esophagitis
    • is more likely to result
    • in chronic occult
  •  
  • Varices
    • Esophageal And Gastric :
    • in the presence of liver disease are life threatening situations precipitated by the inability of the liver to synthesize clotting factors
    • Alcoholism
    • hepatitis B and C
  •  
  • Mucosal tear (Mallory-Weiss)
      • Esophagogastric mucosal tear Initially the patient has vomiting without blood. Continued emesis leads to pain from the tear and eventually the patient develops hematemesis .
  •  
  • Gastritis
      • Diffuse gastritis .
      • Erosions are usually multiple and found primarily in the fundus and body of the stomach.
      • Chronic slow bleeds are most commonly associated with H. pylori
      • Brisk Bleeding : ingested substances as NSAIDs, alcohol, steroids, or other drugs.
  •  
  • Peptic ulcer
      • Most common cause of upper GI bleed 1/2- 2/3.
      • Causes:H. pylori 40-50%,NSAID’s 40-50% andOther (Z-E syndrome)
      • Duodenal bleed is four times more common than gastric ulcer bleed.
      • Duodenal ulcers are usually posterior and involve branches of the gastroduodenal artery.
      • Benign gastric ulcers bleed more than malignant ulcers.
      • There will be significant bleeding in 10-15%
      • surgical intervention is needed in 20%
  • Duodenal ulcers
    • located on the anterior wall are prone to perforation and present as peritonitis and free air.
    • Those on the posterior wall, which is the more common location, lead to bleeding The gastroduodenal artery
  •  
  • Gastric antral vascular ectasia (GAVE) watermelon stomach
    • Dilated small blood vessels in the antrum , or the last part of the Streaky long red areas.
  •  
  • Stress ulcers
      • Acute gastroduodenal lesions that arise after episodes of shock, sepsis, surgery, trauma, burns (curling’s ulcer),
      • or intracrainial pathology or surgery
      • (cushing’s ulcer).
      • The result of bile reflux damage to the gastric protective barrier combined with decreased gastric blood flow secondary to splanchnic vasoconstriction.
      • Sepsis, coagulopathy , and activation of cytokines may also play a role.
  • Dieulafoy’s vascular malformations
      • Dilated Arterial Lesions
  • Other causes
      • Gastric neoplasms :
      • malignant and benign
      • usually mild and chronic.
      • Aorto-enteric fistulas :
      • As a herald bleed followed by a massive bleed
      • In patients with prior aortic reconstructions.
      • Hematobilia :
      • following hepatic injuries or manipulations.
    • الحمد لله