Surgery Resident clinical seminar on the management of a 60yr old male with upper gastrointestinal bleeding presented to the department of surgery, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State

1. Discuss the management of a 60year
old man admitted to the hospital for
hematemesis
By
Dr. Baribote O. S
04 – 04 – 2023

2. Introduction
Surgical importance
Epidemiology
Causes of UGIB
Common presentation
Management
Complications
Prognosis
Conclusion
References
Outline

3. • Upper Gastrointestinal Bleeding (UGIB)
Diagnosis
• Bleeding from a gastrointestinal source
proximal to the ligament of Treitz
Definition:
• Life threatening medical/surgical emergency
• common cause of hospitalization
UGIB
• Variceal
• Non – variceal
Categorized
Introduction

4. Clinical significance
Common, life threatening emergency
Impact on the patient, relatives, society and
the hospital
In-hospital mortality rate
• 5 – 10%
• Rises to 33%
• when bleeding is first observed in patients who
are hospitalized for other reasons

5. Epidemiology
•According to Antunes C. et al
- 80 – 150/100,000 per year
•Male:Female - 2:1
•Prevalence increases with
age (>60years)
Incidence

6. Causes of UGIB
•Esophageal varices
•Esophagitis
•Esophageal ulcer
•Esophageal cancer
•Mallory-Weiss
tear
Esophageal

7. •Gastric varices
•Gastritis
•Gastric ulcer
•Gastric cancer
Gastric

8. •Duodenal ulcer
•Vascular
malformation
including Aorto-
enteric fistulae
Duodenal

9. Condition %
Ulcer 60
Esophageal
Gastric
Duodenal
6
21
33
Erosions 26
Esophageal
Gastric
Duodenal
13
9
4
Mallory-Weiss tear 4
Esophageal varices 4
Tumour 0.5
Vascular lesions e.g Dieulafoy’s disease 0.5
Others 5

10. Causes in Nigeria
• 37%
• Duodenal ulcer – 75%
Peptic Ulcer
• 18.75%
Esophageal varices and gastritis
• 15.6
Gastric cancer
• 9.3%
No obvious pathology

11. Common presentations
• Coffee-ground – indicate slower rate of bleeding
• Fresh blood – indicates rapid bleeding
Hematemesis
• Black tarry offensive stools
• Indicates that blood has been present in the GI tract for
at least 14hours
Melena
• Usually represent a lower GI source
• Can occur in massive brisk bleeding
Hematochezia

12. Management
Preferably co-managed with the physicians
Most UGIB will stop, albeit temporarily while in
a few instances, bleeding with not stop
Principles of management
• Prompt resuscitation
• Investigation to urgently to determine the cause of the
bleeding.
• Definitive treatment
Instances where bleeding does not stop
• Resuscitation, diagnosis and treatment should be carried out

13. Resuscitation
History, examination, resuscitation and relevant
investigations be done simultaneously
Brief History to assess for
• Hx to determine quantity of bleeding and presence of shock
• Hematemesis – duration
• Colour of the vomitus (bright red vs coffee –ground)
• Number of episodes and quantity per episode
• Presence of clots in the vomitus
• History of melena or hematochezia
• Shock
• History of dizziness, generalized weakness, fainting attack,
and dyspnea

14. Assess for signs of shock via examination
and vital signs measurement
• Cold clammy extremities
• Restlessness, confusion, drowsiness or stupor
• Hypotension
• Bradycardia or tachycardia etc
Secure 2 wide bore IV canulla
Group and cross-match blood and
transfusion if urgent PCV is <= 21%
Resuscitation contd

15. Resuscitation contd
Insert urethral catheter to monitor hourly
urinary output
Insert a NG tube to aspirate and do a cold saline
lavage
There is no evidence for the use of intravenous
proton pump inhibitors prior to endoscopy
IV tranexamic acid
Intranasal O2 @ 2L/min

16. • History dyspepsia,
• Epigastric pain with or without radiation to
the back
• smoking
PUD
• Weight loss and epigastric swelling
Gastric cancer
• Prolong vomiting and retching prior to onset
of hematemesis
Mallory Weiss tear
History suggestive of underlying cause

17. • Chronic alcoholism, jaundice and previous
history of liver disease
Esophageal varices
• History of surgery, trauma, burns, severe
sepsis or renal failure
Stress ulcers
• Previous history of aortic surgery with sudden
massive hematemesis +- fainting attack
Aorto-enteric fistula
• Chronic NSAID, aspirin, corticosteriods,
anticoagulant use
Drug history

18. Physical examination
Do a thorough general examination
Examine the systems for possible cause of the
bleeding
Abdomen
• tenderness in the epigastrium, suggestive of peptic ulcer
• hepatosplenomegaly, ascites or spider naevi, suggestive of
oesophageal varices;
• epigastric tumour, suggestive of gastric cancer;
• expansile; pulsating mass suggestive of aorto-enteric fistula.
• DRE
• Fresh blood, melena stool

19. Examination contd
• Palmer erythema – esophageal varices
due to liver cirrhosis
MSS
• Purpura/ecchymosis – bleeding disorders
• Other systemic examination to assess for
comorbid state
Skin

20. Investigation
FBC + differential
• May be normal due to hemoconcentration at presentation
and should be repeated after fluid resuscitation
• Values <=7g/dl should be transfused with red blood cells
Clotting profile
• If features suggest bleeding disorders
Liver function test
Electrolyte Urea and Creatinine
Urinalysis

21. Investigation contd
• Serology or Urea breath test
• If features suggest PUD as the cause of UGIB
H. Pylori
• Rule out perforation and other comobidity
(HHD, COPD etc)
• Secondary tumours in the lung
CXR

22. Investigation contd
• Done after resuscitation and within 24hours of
admission
• Infusion of a prokinetic like erythromycin
• Establish diagnosis and treatment
Endoscopy (Esophagogastroduodenoscopy)
• Double contrast where endoscopy is not available
• Features
• Mucosal defect (Ulcer crater)
• Edematous ring around the ulcer crater (ulcer collar)
• Radiating folds of mucosa away from the ulcer
Barium meal

26. Treatment
Depends on the etiology of the
bleeding
PUD
• Treatment is medical, endoscopic
intervention and surgical
• A comprehensive clinical guideline for the
bleeding ulcer was formulated by ACG in
2020
• Summary of the guideline is as follows

27. Endoscopic therapy is recommended for ulcers with
active spurting or oozing and for non bleeding visible
vessels
Endoscopic therapy with bipolar electrocoagulation,
heater probe, and absolute ethanol injection is
recommended,
hemostatic powder spray TC-325 is suggested for actively
bleeding
low- to very-low-quality evidence also supports clips,
argon plasma coagulation, and soft monopolar
electrocoagulation
ulcers and over-the-scope clips for recurrent ulcer
bleeding after previous successful hemostasis

28. After endoscopic hemostasis, high-dose PPI
therapy is recommended continuously or
intermittently for 3 days, followed by twice-
daily oral proton pump inhibitor for the first 2
weeks of therapy after endoscopy.
Repeat endoscopy is suggested for recurrent
bleeding, and if endoscopic therapy fails,
transcatheter embolization is suggested
Epinephrine only should not be used as an
hemostatic agent

29. •Eradication therapy with triple
therapy
•PPI + Clarithromycin or
Metronidazole + Amoxicillin
•Duration of treatment
•14days
For H. pylori positive

30. Surgery for PUD
• Massive hemorrhage
• Continues hemorrhage
• Significant rebleed after endoscopic
intervention and transcatheter embolisation
• Associated perforation
Indications
• stop the bleeding,
• prevent a recurrence and,
• if possible, cure the underlying cause
Aim of surgery

31. •Often from the gastroduodenal
artery
•Under-run the vessel with a non-
absorbable suture
•Where a giant ulcer destroys the
duodenum, making primary closure
impossible, distal gastrectomy with
roux-en-y reconstruction be done
Bleeding duodenal ulcer

32. •Anterior gastrostomy with
under running of the vessel in
the ulcer bed
•Biopsy of the edges done to
exclusive malignancy
•PPI therapy
Bleeding gastric ulcer

33. Historic procedures for PUD
Vagotomy
• truncal vagotomy and drainage (pyloroplasty
and gastrojejunostomy)
• Selective and Highly selective
Vagotomy + antrectomy
Bilroth I and Bilroth II
No longer widely practice due
• Complications and introduction of effective
acid lowering medications (PPI, H2RA)

34. • 90% bleeding stops spontaneously
• Suture under running is all that is required
Mallory-Weiss tear
• Sclerosant injection and endoscopic clips
• Local excision
Dieufolay’s disease
• Partial gastrecromy is performed if possible.
Gastric Carcinoma

35. • Vasoconstrictor therapy with octreotide
and/or vasopressin
• Propranalol also lowers portal pressure
and be given to prevent rebleed
• Sclerosant injection
• Band ligation
• Balloon tamponade with Sengstaken-
Blakemore tube
• Transjugular intrahepatic portosystemic
stent shunt
Esophageal/gastric varices

36. Endoscopic Band ligation

37. Sengstaken-Blakemore tube

38. Transjugular intrahepatic
portsystemic stent shunt
TIPSS

39. Treatment contd
• Bleeding often stops spontaenously
• Treated conservative with stopping the
offending agent and in giving PPI and
Gastric erosion
• Conservatively with PPI but if numerous,
vagotomy with hemi-gastrectomy can be
performed
Stress Ulcer

40. Algorithm in the Management of UGIB

41. Complications
Shock
Cardiorespiratory
distress
Acute renal injury
Death

42. Prognosis – Rockall Score

43. Conclusion
UGIB is a surgical/medical emergency with high mortality rate
Most cases of UGIB can stop temporarily and the investigation
of choice is an upper GI endoscopy
The principles of management include resuscitation,
investigation to determine cause and institution of definitive
treatment
In most instances, medical and endoscopic intervention will
cause the bleeding to stop
Where the above fails surgical intervention can be done
depending on the cause

44. References
Normal S. Williams, P. Ronan O’Connell, Andrew W. McCaskie
‘Bailey & Love Short Practice of Surgery’ 27th Edition
Laine et al. ACG Clinical Guideline: Upper Gastrointestinal and
Ulcer Bleeding. Am J Gastroenterol 2021;116:899–917.
https://doi.org/10.14309/ajg.0000000000001245
Blatchford O, Murray W.R., Blatchford M. (2000). A risk score to
predict need for treatment for upper-gastrointestinal
haemorrhage. Lancet (London, England), 356(9238), 1318-1321.
Sung J.J, Chan F.K., Chen M., et al. (2011). Pacific working group
consensus on non-variceal upper gastrointestinal bleeding. GUT
(60): 1170-1177.
Badoe, Archampong, Jaja: Principles and Practice of Surgery
including pathology in the Tropics. 5th Edition