Acs0505 Upper Gastrointestinal Bleeding 2008


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Acs0505 Upper Gastrointestinal Bleeding 2008

  1. 1. © 2008 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 5 UPPER GASTROINTESTINAL BLEEDING — 1 5 UPPER GASTROIN TESTINAL BLEEDING Eric S. Hungness, M.D., F.A.C.S. Despite recent advances in therapeutic endoscopy and the through which lactated Ringer solution or 0.9% normal saline widespread use of antisecretory medications, upper gastroin- should be infused at a rate high enough to maintain tissue perfu- testinal bleeding (UGIB)—defined as bleeding that occurs sion. A urinary catheter should be inserted and urine output mon- proximal to the ligament of Treitz—continues to be one of the itored. Blood products should be given as necessary, and any coag- more common reasons for surgical consultation. It also ulopathies should be corrected. It is all too easy to forget these basic remains a significant source of mortality for both emergency steps in a desire to evaluate and manage massive GI hemorrhage. admissions (11%) and inpatients (33%).1 The most common Every effort should be made to resuscitate and stabilize the causes of UGIB are esophageal (varices and Mallory-Weiss patient sufficiently to allow clinical evaluation and esophagogas- tears), gastric (acute hemorrhagic gastritis, varices, ulcers, and troduodenoscopy (EGD) to help determine the cause of the neoplasms), and duodenal (ulcers) [see Management of bleeding and direct subsequent care. Only if the patient remains Specific Sources of Upper GI Bleeding, below]. Less common unstable and continues to bleed despite maximal supportive mea- causes include various other GI conditions and certain hepato- sures should he or she be taken to the operating room for intraop- biliary and pancreatic disorders. erative diagnosis as a last resort. In such cases, the abdomen should be opened through an upper midline incision, and an ante- rior gastrotomy should be performed. If inspection does not reveal Presentation and Initial the source of the bleeding or if bleeding is observed beyond the Management pylorus, a duodenotomy is made, with care taken to preserve the Upper gastrointestinal pylorus if possible. Bleeding from the proximal stomach may be hemorrhage may present difficult to verify, but it should be actively sought if no other bleed- as severe bleeding with ing site is identified. Intraoperative endoscopy should be consid- hematemesis, hematoche- ered in this situation. zia, and hypotension; as gradual bleeding with melena; or as occult bleeding detected by positive tests for blood Clinical Evaluation in the stool. The initial steps in the evaluation of patients with Only after the initial UGIB are based on the perceived rate of bleeding and the measures to protect the air- degree of hemodynamic stability. Hemodynamically stable way and stabilize the patients who show no evidence of active bleeding or comorbidi- patient have been complet- ties and in whom endoscopic findings are favorable may be ed should an attempt be treated on an outpatient basis,2 whereas patients who show evi- made to establish the cause dence of serious bleeding should be managed aggressively and of the bleeding.The history hospitalized. should focus on known causes of UGIB (e.g., ulcers, recent trau- The airway, breathing, and circulation should be rapidly ma or stress, liver disease, varices, alcoholism, and vomiting) and assessed, and the examiner should note whether the patient has a on the possible use of medications that interfere with coagulation history of or currently exhibits hematemesis, melena, or hema- (e.g., warfarin, aspirin, nonsteroidal anti-inflammatory drugs tochezia. Blood should be drawn for a complete blood count, [NSAIDs], and dipyridamole) or alter hemodynamics (e.g., beta blood chemistries (including tests of liver function and renal func- blockers and antihypertensive agents). The cardiac history is par- tion), and measurement of the prothrombin time (PT) and the ticularly important for assessing the patient’s ability to withstand partial thromboplastin time (PTT). Blood should be sent to the varying degrees of anemia. blood bank for typing and crossmatching. The physical examination is seldom of much help in determin- If the patient is stable and shows no evidence of recent or active ing the exact site of bleeding, but it may reveal jaundice, ascites, or hemorrhage, the surgeon may proceed with the workup. If, how- other signs of hepatic disease; a tumor mass; or a bruit from an ever, the patient is stable but shows evidence of recent or active abdominal vascular lesion. bleeding, short, large-bore intravenous lines should be placed The next step is nasogastric aspiration. A bloody aspirate is before workup is begun to ensure that immediate I.V. access is an indication for EGD, as is a clear, nonbilious aspirate if a possible should the patient subsequently become unstable. bleeding site distal to the pylorus has not been excluded. If the If the patient is unstable, he or she should be taken to an inten- aspirate is clear and bile-stained, the source of the bleeding is sive care unit and resuscitated immediately. Resuscitation of an unlikely to be the stomach, the duodenum, the liver, the biliary unstable patient is begun by establishing a secure airway and ensur- tree, or the pancreas. Nonetheless, if subsequent evaluation of ing adequate ventilation.3,4 Oxygen should be given, with a low the lower GI tract for the source of the bleeding is unrewarding, threshold for endotracheal intubation. Much as in trauma resusci- an upper GI site that had stopped bleeding when the nasogas- tation, either short, large-bore peripheral I.V. lines or a single- tric tube was passed or that was distal to the ligament of Treitz lumen 8 French catheter in the femoral vein should then be placed, should still be considered.
  2. 2. © 2008 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 5 UPPER GASTROINTESTINAL BLEEDING — 2 Assessment and Management of Upper Gastrointestinal Bleeding Patient is stable Patient presents with upper GI bleeding Proceed with workup. If active bleeding is present: insert large-bore I.V. line before workup. Perform initial assessment and management Patient stabilizes Evaluate airway, breathing, and circulation. Proceed with workup. Look for past or current hematemesis, melena, Patient is unstable or hematochezia. Draw blood for CBC, blood chemistries, Give oxygen by mask or by measurement of PT and PTT, and typing and ET tube and ventilator. crossmatching. Insert large-bore I.V. line, Patient remains unstable and infuse lactated Ringer solution. Proceed to OR for Insert urinary catheter, and intraoperative diagnosis monitor urine output. and management. Give blood as needed. Correct any coagulopathies. Manage specific source of upper GI bleeding. Duodenal ulcer Esophageal Mallory-Weiss tear Gastric neoplasm varices [See Figure 1.] Lesion usually stops [See Figure 2.] bleeding without therapy. If it does not, control bleeding endoscopically. Lesion is benign Lesion is malignant Gastric ulcer If bleeding stops: [See Figure 1.] Gastric observe. Perform wedge Attempt endoscopic varices If bleeding continues: excision of lesion. control of bleeding. perform anterior If bleeding stops: [See Figure 2.] gastrotomy with direct excise lesion electively. suture ligation of tear. If bleeding continues: excise resectable lesions promptly; nonresectable lesions call for a Acute hemorrhagic gastritis nonoperative approach. Stop NSAIDs. Give H2 receptor blockers, omeprazole, sucralfate, or antacids. Give anti–Helicobacter pylori therapy. If bleeding stops: observe. If bleeding continues: consider I.V. somatostatin (250 g bolus, then 250 g/hr) or intra-arterial vasopressin (10 U/hr). If this step is effective, observe; if not, perform total or near-total gastrectomy [see 5:20 Procedures for Benign and Malignant Gastric and Duodenal Disease].
  3. 3. © 2008 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 5 UPPER GASTROINTESTINAL BLEEDING — 3 Work up patient Obtain history, focusing on known causes of upper GI bleeding and suspect medications. Perform physical examination. Perform NG aspiration. Perform esophagogastroduodenoscopy [see 5:18 Gastrointestinal Endoscopy]. Use other tests as appropriate: • tagged red cell scans • arteriography • intraoperative endoscopic exploration Dieulafoy lesion Hemosuccus pancreaticus Vascular ectasias Duodenal diverticula Attempt endoscopic Perform distal pancreatectomy Attempt endoscopic control control. Mark site with [see 5:24 Procedures for Benign of bleeding. Excise lesion, with India ink. and Malignant Pancreatic Consider I.V. somatostatin or without the aid If bleeding stops: observe. Disease], including excision of (250 g bolus, then 250 g/hr). of intraoperative pseudocyst and ligation of endoscopy. If bleeding continues: If bleeding stops: observe. bleeding vessel. ligate or excise vessel. If bleeding continues: resect lesion. Hiatal hernia Hemobilia Aortoenteric fistula Perform arteriographic Resect aortic graft. embolization of affected Close enteric site of portion of liver. fistula. Other options are hepatic Place extra-anatomic artery ligation and hepatic or in situ arterial graft. resection. Paraesophageal hernia Sliding hernia (type I hiatal hernia) (type II–IV hiatal hernia) Give PPI and, if applicable, anti–H. pylori therapy. Repair surgically (either If bleeding stops: continue medical therapy. via open laparotomy or via minimally invasive If bleeding continues: perform Nissen fundoplication approach) [see 4:7 Open [see 4:7 Open Esophageal Procedures and Esophageal Procedures 4:8 Minimally Invasive Esophageal Procedures]. and 4:8 Minimally Invasive Esophageal Procedures].
  4. 4. © 2008 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 5 UPPER GASTROINTESTINAL BLEEDING — 4 Investigative Studies Patient has bleeding from duodenal or gastric ulcer ESOPHAGOGASTRODUODENOSCOPY Initiate medical management. EGD [see 5:18 Gastrointestinal Endoscopy] almost always • PPI infusion reveals the source of UGIB; its utility and accuracy have been Attempt to control bleeding endoscopically. well documented in the literature.5,6 Performance of this proce- dure requires considerable skill: identification of bleeding sites in a blood-filled stomach is far from easy. Hematemesis is an indi- cation for emergency EGD, usually within 1 hour of presenta- tion. If the rate of bleeding is high, saline lavage may be per- Bleeding continues formed to clear the stomach of blood and clots. If the rate of Repeat attempt at bleeding is moderate or low, as is often the case in patients with endoscopic control. melena, urgent EGD is indicated. EGD is not only an excellent diagnostic tool but also a valuable therapeutic modality. Indeed, most upper GI hemorrhages may be controlled endoscopically, though the degree of success to be Bleeding continues Bleeding stops expected in individual cases varies according to the expertise of the endoscopist and the specific cause of the bleeding. Proceed to OR for Continue medical management. Therapeutic endoscopic maneuvers include injection, thermal surgical treatment. • PPI infusion coagulation, and mechanical occlusion of bleeding sites (clip • H. pylori therapy, if necessary application or variceal banding). The choice of therapy depends on the cause, the site, and the rate of bleeding. OTHER IMAGING Patient has duodenal ulcer Patient has gastric ulcer Tagged red cell scans may confirm the presence of an active Perform duodenotomy and Treat according to ulcer type. bleeding site; however, scans are fairly nonspecific with respect to oversew ulcer. • Type I: wedge resection determining the anatomic location of the bleeding.7 Consider truncal vagotomy • Type II/III: antrectomy, Billroth I Arteriography may demonstrate that a lesion is present, but it can- (if patient is unstable) or reconstruction, and vagotomy not reliably identify a bleeding site unless the bleeding is brisk (> highly selective vagotomy • Type IV: Csendes procedure 1 ml/min). Occasionally, arteriography reveals the cause of the (if patient is stable). or ligation of left gastric artery bleeding even if the bleeding has stopped. Angiography may also with oversewing of ulcer be considered as a therapeutic modality for high-risk surgical • Type V: as for acute hemorrhagic patients.8 These tests, in conjunction with EGD, should allow the gastritis surgeon to establish the cause of upper GI bleeding more than 90% of the time. Figure 1 Shown is an algorithm for management of bleeding from duodenal or gastric ulcers. Management of Specific Sources of Upper GI therapy. In addition, certain patients whose bleeding is controlled Bleeding endoscopically (e.g., those with a visible vessel, active bleeding, or an adherent clot,11 as well as those with giant ulcers) should be DUODENAL ULCER strongly considered for surgical therapy. The development of If bleeding is controlled endoscopically, then a proton pump effective medical regimens inhibitor (PPI), such as pantoprazole, should be given intra- for controlling uncompli- venously, either in a bolus twice daily or by continuous infusion.12 cated duodenal ulcers has led to a drastic reduction in the num- In addition, antibiotic therapy directed against Helicobacter pylori ber of elective surgical procedures performed for this purpose. (e.g., a 14-day course of metronidazole, 500 mg p.o., t.i.d.; Nevertheless, the incidence of bleeding from duodenal ulcers that omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500 mg p.o., is severe enough to necessitate emergency endoscopic or operative b.i.d.) should be considered if the organism is present; such ther- intervention has not decreased over the past decade.9 apy has been shown to reduce rebleeding rates after antacid med- Once EGD has demonstrated that a duodenal ulcer is the ication has been stopped.13 Food need not be withheld unless the source of the bleeding, the first question that must be addressed likelihood of rebleeding is high, because resumption of oral feed- is whether active bleeding is present. If it is, an attempt should be ing does not appear to affect rebleeding rates.14 If bleeding recurs made to control the hemorrhage endoscopically [see Figure 1].10 despite medical and endoscopic therapy, a second attempt at Because ongoing blood loss eventually leads to coagulopathies, endoscopic control should be made. Repeat endoscopic treatment the surgeon must exercise good judgment in deciding how long to reduces the need for surgery without increasing the risk of death pursue endoscopic treatment before concluding that such treat- and is associated with fewer complications than surgery is.15 ment has failed and that surgical treatment is necessary. In gener- Surgical management may be accomplished either laparoscop- al, substantial bleeding (six units or more) or bleeding that is not ically or via an open approach [see 5:20 Procedures for Benign and controlled endoscopically is an indication for surgical interven- Malignant Gastric and Duodenal Disease].The latter begins with an tion. Likewise, ongoing hemorrhage in a hemodynamically unsta- upper midline incision.The duodenum is mobilized and an ante- ble patient (especially an elderly one) calls for immediate surgical rior longitudinal duodenotomy performed over the site of the
  5. 5. © 2008 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 5 UPPER GASTROINTESTINAL BLEEDING — 5 ulcer.The bleeding vessel, which is usually on the posterior wall of approach consists of antrectomy with Billroth I reconstruction and the first portion of the duodenum, is ligated with non-absorbable truncal vagotomy [see 5:20 Procedures for Benign and Malignant sutures at sites proximal and distal to the bleeding point. A third Gastric and Duodenal Disease].Type IV ulcers can pose a technical stitch is placed posterior to the bleeding vessel. Pains must be challenge as a consequence of their close proximity to the esoph- taken to avoid injury to the common bile duct during the place- agogastric junction. A distal gastrectomy with a tongue-shaped ment of these sutures.The duodenotomy is then closed. If a trun- extension upward along the lesser curvature to incorporate the cal vagotomy is to be performed, the duodenotomy should extend ulcer, followed by a Roux-en-Y reconstruction (the Csendes pro- through the pylorus and closed transversely to perform a pyloro- cedure), is often required.19 Another option is ligation of the left plasty. Frozen section to confirm the presence of nerve tissue is gastric artery, followed by biopsy and oversewing of the ulcer. helpful for ensuring that the vagotomy is complete. ESOPHAGEAL VARICES The recommendation for truncal vagotomy is based on data from studies done before PPIs and H. pylori therapy came into The value of endoscopy use. Subsequent studies and a 2004 Cochrane review that evalu- in the diagnosis and man- ated rebleeding rates with current medical regimens demonstrate agement of variceal bleed- much lower rebleeding rates.16 Furthermore, it seems probable ing cannot be overempha- that long-term PPI therapy (the medical equivalent of vagotomy), sized. Even in patients with in conjunction with eradication of H. pylori and avoidance of known varices, the site of NSAIDs, should reduce rebleeding rates significantly. Studies bleeding is frequently non- from the United States9 and the United Kingdom17 have shown variceal; endoscopy is therefore essential.20 If bleeding varices are that a vagotomy is performed less than 50% of the time during identified, rubber banding or intravariceal sclerotherapy with a surgical treatment of an acute bleeding duodenal ulcer.Therefore, sclerosing agent (1.5% sodium tetradecyl sulfate, ethanolamine, although there are no prospective, randomized studies to support sodium morrhuate, or absolute alcohol) is performed [see Figure it, one may consider an alternative treatment approach in patients 2].21,22 If these measures do not control the hemorrhage, balloon who have not been receiving ulcer therapy before the bleeding tamponade is indicated.23 Patients who are to undergo this proce- began—namely, ligation of the bleeding vessel, postoperative dure require an endotracheal tube. The preferred tube to use for administration of PPIs, and H.pylori therapy.This approach avoids balloon tamponade is the four-port Minnesota tube, although the the complications associated with truncal vagotomy. Sengstaken-Blakemore tube is also acceptable. The Minnesota Another option for preventing postvagotomy symptoms when tube has a gastric balloon, an esophageal balloon, and aspiration operating on stable patients for bleeding duodenal ulcer is to per- ports for the esophagus and the stomach. The gastric balloon is form a highly selective vagotomy (HSV) [see 5:20 Procedures for inflated first and placed on traction. If the bleeding is not con- Benign and Malignant Gastric and Duodenal Disease]. This proce- trolled, the esophageal balloon is then inflated.The pressure in the dure is considered preferable to truncal vagotomy because of the balloons should be released in 24 to 48 hours to prevent necrosis decreased incidence of gastric atony, alkaline reflux gastritis, of the esophageal or the gastric wall. Successful balloon tampon- dumping, and diarrhea; however, HSV is associated with a higher ade is followed by endoscopic variceal injection or variceal banding. recurrence rate than truncal vagotomy is.18 Intravenous somatostatin (250 μg bolus, followed by infusion of 250 μg/hr) should be administered in conjunction with the above- GASTRIC ULCER mentioned steps.Vasopressin (10 U/hr) may also be given; howev- Gastric ulcers are classi- er, it causes diffuse vasoconstriction, and nitroglycerin is required fied according to their loca- to alleviate cardiac side effects. Somatostatin has proved superior tion and to the role (if any) to placebo in controlling variceal hemorrhage when used in con- that gastric acid hypersecre- junction with endoscopic sclerotherapy.24 It is as effective as vaso- tion plays in their develop- pressin while giving rise to fewer side effects. Octreotide, a synthet- ment. Type I ulcers are ic analogue of somatostatin, shares many of the properties of located on the lesser curva- somatostatin but perhaps not all. Both agents decrease secretion of ture and are not associated with acid secretion. Type II ulcers are gastric acid and pepsin; however, the decreased gastric blood flow associated with high acid secretion and are located on the lesser observed with somatostatin administration has not been reported curvature, occurring in synchrony with duodenal ulcers. Type III with octreotide administration. Nevertheless, some clinicians in ulcers have a similar location and are also associated with acid the United States elect to use octreotide (25 to 50 μg/hr) in place hypersecretion but occur in synchrony with ulcers in the prepy- of I.V. somatostatin because the former tends to be more widely loric region. Type IV ulcers are not associated with acid secretion available. Multiple prospective, randomized trials showed that and are located in the cardia near the esophagogastric junction. propranolol (40 mg b.i.d., p.o.) decreased the incidence of first- Type V ulcers are diffuse and are related to the use of medications time variceal bleeding as well as the incidence of recurrent variceal (e.g., NSAIDs) [see Acute Hemorrhagic Gastritis, below]. bleeding.25-27 Propranolol should not be used during active bleed- Bleeding is less common than with duodenal ulcers, but initial ing but should be started once bleeding stops. management of a bleeding gastric ulcer is the same as that of a After the acute variceal bleeding has been controlled, any duodenal ulcer (i.e., endoscopic control) [see Figure 1].To prevent remaining varices should be subjected to injection sclerotherapy or aggravation of the bleeding, early biopsy generally is not recom- banding at 2-week intervals until they too are obliterated. mended; repeat endoscopy and biopsy are done at a later date.The The main indications for surgical intervention in patients with indications for emergency surgical intervention for gastric ulcers bleeding esophageal varices are uncontrolled hemorrhage and per- are the same as those for duodenal ulcers. sistent rebleeding despite endoscopic and medical therapy. When Bleeding gastric ulcers that necessitate operative intervention such intervention is considered, it is essential to determine whether should be treated with resection. For type I ulcers, wedge resection the patient is a transplant candidate. If so, operation should be is typically performed. For type II and III ulcers, the usual avoided and bleeding managed by decompressing the portal
  6. 6. © 2008 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 5 UPPER GASTROINTESTINAL BLEEDING — 6 Patient has bleeding from esophageal or gastric varices Attempt to control hemorrhage endoscopically with intravariceal injection sclerotherapy or rubber banding (gastric varices are less amenable to sclerotherapy). Give I.V. somatostatin (250 g bolus, then 250 g/hr). Octreotide (25–50 g/hr) is an alternative. Bleeding stops Bleeding continues If any varices remain, repeat injection Pass 4-port Minnesota tube, and perform sclerotherapy or banding at 2-wk intervals balloon tamponade. until varices are gone. Give propranolol p.o. Bleeding does not recur Bleeding recurs Bleeding continues Bleeding stops Perform intravariceal injection sclerotherapy or rubber banding. If any varices remain, repeat sclero- Initiate surgical management. therapy or banding at 2-wk intervals until varices are gone. Give propranolol p.o. Patient is a transplant candidate Patient is a transplant candidate Patient is not a transplant candidate Decompress portal venous system with transjugular intra- Decompress portal venous system with transjugular intra- Procedure of choice depends on patient status. hepatic portacaval shunt (TIPS). Proceed with transplantation hepatic portosystemic shunt (TIPS). Proceed with transplantation when suitable organ is obtained. when suitable organ is obtained. Patient is stable Patient is unstable Figure 2 Shown is an Obtain arteriograms with views of portal vein and Perform central portacaval shunting procedure algorithm for management left renal vein. (usually side to side or with short PTFE interposition of bleeding from esophageal If venous anatomy is suitable: perform distal graft). or gastric varices. splenorenal shunting procedure. Alternatively, consider esophageal transection If venous anatomy is not suitable: consider (for esophageal varices only) or suture ligation esophageal transection (for esophageal varices of bleeding gastric varices. only) or mesocaval or portacaval shunt. venous system with a transjugular intrahepatic portosystemic tion is also a reasonable choice. This procedure is associated with shunt (TIPS) [see 5:10 Portal Hypertension]. TIPS significantly a lower incidence of encephalopathy than a portacaval shunting reduces rebleeding rates, but it poses a risk of encephalopathy.28 procedure; however, it is associated with higher rates of rebleeding If the patient is not a transplant candidate and is not actively (particularly late rebleeding), and it can be difficult to perform bleeding, a distal splenorenal shunt (DSRS) is preferable.29 when active bleeding is present. Suture ligation of the bleeding Arteriograms with views of the portal vein and the left renal vein varices with devascularization (the Sugiura procedure) [see 5:10 are obtained. Alternatively, computed tomographic angiography Portal Hypertension] should also be considered. with three-dimensional reconstruction may be performed. If the In general, prognosis is related to the underlying liver disease. venous anatomy is suitable—that is, if the diameter of the splenic For example, patients with varices that are secondary to chronic vein is greater than 0.75 cm (preferably greater than 1.0 cm) and extrahepatic portal venous or splenic venous occlusion generally the vein is within one vertebral body of the renal vein on venogra- have a much better prognosis than those whose portal hypertension phy—a DSRS procedure should be feasible. If the venous anato- is secondary to hepatic parenchymal causes.The severity of the cir- my is not suitable, then esophageal transection, a mesocaval rhosis also determines short-term and long-term survival and may venous graft, or a portacaval shunt is required. influence the decision whether to perform a shunting procedure. In the emergency setting, a central portacaval shunt, usually in For varices that are secondary to splenic vein thrombosis (sinistral a side-to-side orientation or with a short polytetrafluoroethylene portal hypertension), splenectomy is usually curative; the proce- (PTFE) interposition graft, may be placed. Esophageal transec- dure may be performed laparoscopically [see 5:25 Splenectomy].30
  7. 7. © 2008 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 5 UPPER GASTROINTESTINAL BLEEDING — 7 GASTRIC VARICES present as a submucosal mass that may cause bleeding as a result Gastric varices are man- of mucosal ulceration. The bleeding may be treated with wedge aged in much the same way excision of the tumor, which can be challenging when the GIST as esophageal varices [see is located in the gastric cardia. Such excision can often be accom- Figure 2], though they are plished laparoscopically [see 5:20 Procedures for Benign and less amenable to sclerother- Malignant Gastric and Duodenal Disease] or even through a laparo- apy.31 Other endoscopic scopic intragastric approach.36 Some surgeons now perform full- treatments (e.g., ligation or thickness wedge resections endoscopically with the use of a flexi- sclerotherapy plus ligation) and interventional radiologic treat- ble stapler.37 ments (e.g., TIPS or intravascular balloon occlusion) should be Bleeding from malignant neoplasms, whether early stage or late considered before surgical management (i.e., DSRS, portosys- stage, generally can be controlled initially by endoscopic means; temic shunting, or suture ligation with gastric devascularization). however, rebleeding rates are high.38 If the lesion is resectable, it If the patient is a suitable candidate, liver transplantation may be should be excised promptly once the patient is stable (provided performed as an alternative to shunting. that it has been appropriately staged). If disease is advanced, how- ever, surgical options are limited, and a nonoperative approach, MALLORY-WEISS TEARS though necessarily imperfect, is preferable.39 Mallory-Weiss tears are HIATAL HERNIA linear tears at the esopha- gogastric junction that are Not infrequently, the usually caused by vomit- source of chronic enteric ing. Any patient who pre- blood loss is a hiatal her- sents with vomiting that nia. Major bleeding is rare initially is not bloody but in this condition but may later turns so should be suspected of having a Mallory-Weiss occur as a result of linear tear. As a rule, these lesions stop bleeding without therapy. If erosions at the level of the bleeding is substantial or persistent, however, endoscopic injec- diaphragm (Cameron tion, clipping, banding, or coagulation may be necessary.32,33 In lesions),40 gastritis within the hernia, or torsion of a parae- rare instances, the tear will have to be oversewn at operation. sophageal hernia. Endoscopy is generally diagnostic, though the This is accomplished via an anterior gastrotomy and direct sources of chronic blood loss are not always obvious. Recognition suture ligation of the tear. that the bleeding derives from a Cameron lesion should incline the surgeon toward operative intervention [see 4:7 Open ACUTE HEMORRHAGIC Esophageal Procedures and 4:8 Minimally Invasive Esophageal GASTRITIS Procedures]; this lesion is usually mechanically induced and there- Bleeding from gastritis is fore tends to be less responsive to antacid therapy. virtually always managed Chronic bleeding from a type I hiatal hernia should be treated medically with H2 blockers, initially with a PPI. H. pylori therapy should be added if biopsy PPIs, sucralfate, or antacids shows this organism to be present. Operative management (i.e., (either alone or in combi- laparoscopic Nissen fundoplication [see 4:5 Minimally Invasive nation), along with antibi- Esophageal Procedures]) should be considered for fit patients who otics if H. pylori is present.34 Somatostatin may be beneficial. have complications associated with their hiatal hernia and for all Sometimes, administration of vasopressin via the left gastric artery symptomatic patients with type II, III, or IV hiatal hernias (laparo- is needed to control bleeding. In rare cases, total or near-total gas- scopic paraesophageal hernia repair).41 trectomy [see 5:20 Procedures for Benign and Malignant Gastric and DIEULAFOY LESION Duodenal Disease] is required; however, the mortality associated with this operation in this setting is high. Stress ulcer prophylaxis A Dieulafoy lesion is the in severely ill or traumatized patients is essential to prevent this rupturing of a 1 to 3 mm problem.35 The gastric pH should be kept as close to neutral as bleeding vessel through the possible. If the gastritis is relatively mild, a biopsy specimen should gastric mucosa without sur- be obtained and tested for H. pylori. Treatment consists of acid rounding ulceration. This reduction and H. pylori therapy. lesion most commonly is found high on the lesser NEOPLASMS curvature, but it can also occur anywhere throughout the GI tract. Benign tumors of the Histologic studies have not revealed any intrinsic abnormalities upper GI tract (e.g., gas- either of the mucosa or of the vessel. trointestinal stromal tu- Initial treatment consists of either coagulation of the bleed- mors [GISTs], hamarto- ing vessel with a heater probe or mechanical control with clips mas, and hemangiomas) or rubber bands; local injection of epinephrine may help con- occasionally bleed [see 5:8 trol acute hemorrhage while this is being done. In skilled hands, Tumors of the Stomach, Duo- endoscopic therapy has a 95% success rate, and long-term con- denum, and Small Bowel]. trol is excellent. If endoscopic therapy fails, surgical options, Wedge excision of the offending lesion is the procedure of choice. including ligation or excision of the vessel involved, come into GISTs (previously classified as leiomyomas or leiomyosarcomas) play.42 Having the endoscopist mark the site with India ink is run the gamut from benign to highly aggressive. They typically helpful for localization.
  8. 8. © 2008 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 5 UPPER GASTROINTESTINAL BLEEDING — 8 HEMOBILIA tic surgery (secondary).47 A common initial manifestation Hemobilia should be sus- of an aortoenteric fistula is a small herald bleed that is fol- pected in all patients who lowed a few days later by a massive hemorrhage. Patients present with the classic triad often present with the triad of GI hemorrhage, a pulsatile of epigastric and right upper mass, and infection; however, not all of these symptoms are quadrant pain, GI bleeding, invariably present. A high index of suspicion facilitates diag- and jaundice; however, only nosis. Endoscopy may show an aortic graft eroding into the about 40% of patients with enteric lumen, but this is an uncommon finding. CT scan- hemobilia present with the entire triad. Endoscopy demonstrating ning is the procedure of choice for diagnosis. The finding of blood coming from the ampulla of Vater points to a source in the air around the aorta or the aortic graft is diagnostic and is an biliary tree or the pancreas (hemosuccus pancreaticus). indication for emergency exploration. The preferred surgical Arteriography may provide the definitive diagnosis: a bleeding treatment is resection of the graft with extra-abdominal tumor, a ruptured artery from trauma, or another cause.43 bypass. Some authorities, however, advocate resection of the Arteriographic embolization of the affected portion of the liver is graft with in situ graft replacement.48 Some now advocate the preferred treatment option; hepatic artery ligation (selective if endovascular stent repair for high-risk patients without evi- possible) or hepatic resection [see 5:23 Hepatic Resection] may be dence of infection.49 required.44 VASCULAR ECTASIAS HEMOSUCCUS Vascular ectasias (also PANCREATICUS referred to as vascular dys- Bleeding into the pancre- plasia, angiodysplasia, angio- atic duct, generally from mata, telangiectasia, and erosion of a pancreatic arteriovenous malforma- pseudocyst into the splenic tions) may bleed briskly. As artery, is signaled by upper a rule, gastric lesions can abdominal pain followed by be readily identified and the bleeding controlled by endoscop- hematochezia.45 If endoscopy is performed when hematochezia is ic means.50 Lesions that continue to bleed, either acutely or present, the bleeding site may not be seen; however, if endoscopy chronically, despite endoscopic measures should be excised. is performed when pain is first noted, blood may be seen coming Some patients have multiple and extensive lesions that necessi- from the ampulla of Vater. The combination of significant GI tate resection of large portions of the stomach. bleeding, abdominal pain, a history of alcohol abuse or pancreati- Pharmacotherapy and hormone therapy have been tried; the tis, and hyperamylasemia should suggest the diagnosis. If there are results have been mixed. no pancreatitis-related indications for surgery, angiographic DUODENAL embolization can be definitive treatment.46 If there are pancreati- DIVERTICULA tis-related indications for operation, angiographic embolization may allow an elective operative procedure based on the structural Duodenal diverticula changes observed in the pancreas. If embolization fails, pancreatic are rare causes of UGIB. resection is usually required, often on an emergency basis [see 5:24 Accurate identification of Procedures for Benign and Malignant Pancreatic Disease]. a bleeding site within a given diverticulum is diffi- AORTOENTERIC FISTULA cult, but an attempt Aortoenteric fistulas should be made to accomplish this by means of peroral may occur spontaneously enteroscopy or video capsule endoscopy. Excision is the pre- as a result of rupture of ferred treatment and is accomplished by means of segmental an aortic aneurysm or resection.51 Great care must be taken in the treatment of duo- perforation of a duodenal denal diverticula in the region of the ampulla of Vater to ensure lesion (primary); more that the pancreatic duct and the bile ducts are not injured dur- often, they arise after aor- ing excision.
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Gisbert JP, Khorrami S, Carballo F, et al: H. pylori Mallory-Weiss syndrome with active bleeding. eradication therapy vs. antisecretory non-eradica- Gastrointest Endosc 55:842, 2002 Acknowledgment tion therapy (with or without long-term mainte- 33. Park CH, Min SW, Sohn YH, et al: A prospective, nance antisecretory therapy) for the prevention of randomized trial of endoscopic band ligation vs. Portions of this chapter are based on a previous itera- recurrent bleeding from peptic ulcer. Cochrane epinephrine injection for actively bleeding tion written for ACS Surgery by Kristi L. Harold, Database Syst Rev (2):CD004062, 2004 Mallory-Weiss syndrome. Gastrointest Endosc M.D., F.A.C.S., and Richard T. Schlinkert, M.D., 17. Gilliam AD, Speake WJ, Lobo DN, et al: Current 60:22, 2004 F.A.C.S. The author wishes to thank Drs. Harold and practice of emergency vagotomy and Helicobacter 34. Metz CA, Livingston DH, Smith JS, et al: Impact Schlinkert.