3. Qualities
● Patient – stable vs. unstable
● Intermittent vs. constant bleed
● Symptoms
● H&P
● CBC, coags, LFTs – anemia and evaluation for
bleeding tendencies
● Bright vs. dark
● Blood per os or rectum
4. Starting Tests
● NGT placement with
gastric lavage
● Not very sensitive
● Probably better suited
to cleaning the
stomach in preparation
for endoscopy.
5. Localize the Bleed
● EGD – excellent in identifying sources proximal to
the second portion of the duodenum.
● Also has therapeutic potential in the right hands.
● Tagged RBC Scan – designed for slow and
intermittent GI bleeds. Can pick up bleeds as slow
as 0.1 mL/min. Terrible for precise localization.
6. Localize the Bleed
● Angiography – slightly more brisk bleeding at
around 1 mL/min (as low as 0.5 mL/min). Precise
localization. Can embolize.
● Can also provoke with 24hrs of heparin gtt and
repeat angiogram – a 2001 study out of Canada
showed an increase in source identification from
33% to 67% w/ heparin.
● Survey celiac axis, SMA, and IMA
7. Localize the Bleed
● CTA – 0.3 mL/min – look for blush
● Capsule endoscopy – takes about 50,000 photos
over 6-8 hrs. Images wirelessly transmitted to a
receiver. Diagnostic for SB bleeding without
therapeutic option.
● Do not administer to patients with pSBO, SBO,
LBO, strictures, etc.
9. What to do?
● If suspect or prove ulcer in stomach or duodenum –
start PPI gtt. (2005 Cochrane review out of
Northwestern showed only minimal reductions in
transfusion requirements and LOS).
● Probably best to treat empirically for H.pylori with
PPI, flagyl, and clarithromycin for 14 days.
● On test, if bleeding requires 6 units/24hrs and is
ongoing or patient becomes unstable, proceed to
OR.
● Will talk about what to do in OR later.
10. EGD
● Can inject 30mL of 1:10,000 epinephrine into ulcer
● Electrocautery – e.g. Gold Probe
● Argon plasma coagulation
● Thermal probe
● Hemostatic clips
11.
12. Gastric Ulcer Types
● Types 1 & 4 – no correlation to acid production
● Types 2 & 3 – correlated with acid production
● Type 5 – diffuse and related to medications (e.g.
NSAIDs)
13. OR
● Most bleeding
duodenal ulcers are
located on the
posterior wall of the 1st
portion near GDA.
● Duodenotomy with
oversewing and biopsy
of ulcer
● Reinforce with a
Graham patch.
14. OR
● Consider truncal vagotomy with pyloroplasty.
● However, the efficacy of modern acid suppressants
may negate the benefits and reduce the associated
morbidity of vagotomies.
15. OR
● For gastric ulcers, an anterior gastrotomy is made
transversely, parallel to the vessels to explore the
stomach.
● Bleeding ulcers should be oversewn and biopsied.
● For types 2 & 3 – consider truncal vagotomy.
● Wedge resection is a feasible option
● Need repeat EGD in about 6 weeks to ensure
healing of ulcers.
18. Varices
● Endoscopic management is first line
● If exsanguinating can use Minnesota or Sengstaken-
Blakemore tube – must intubate, only keep inflated for 1-
2 days.
● Need to decrease portal HTN
● TIPS, splenorenal shunt, mesocaval shunt, portacaval
shunt, etc.
● Propanolol – do not give if patient is in hemorrhagic
shock.
● If varices 2/2 cirrhosis – calculate MELD score and notify
Transplant center.
20. 2012 ABSITE Question
● Describe a portosystemic shunt that maintains
hepatopetal flow (i.e. toward the liver).
21. Answer
● Mesocaval H-shunt – SMV connected to the IVC
with PTFE or Dacron graft
● Small <8mm side-to-side portacaval shunt
● Goal is to maintain portal pressures less than 12
mmHg.
22. Splenorenal Shunt
● Rarely performed – though has been performed a
couple of times at LBJ in the past few years.
● Look for a dilated splenic vein ~1 cm within 2-3 cm
of the left renal vein
● Note sinistral hypertension from thrombus 2/2
pancreatitis can give isolated esophageal varices
without caput medusae and other findings of portal
HTN
● Rx - splenectomy
25. Endoscopic Maneuvers
● First attempt banding or hemostatic clip application
– SAGES recommendation
● Next consider sclerosants
● Sodium morrhuate – available at Hermann – most
commonly used at our hospital
● Absolute alcohol is the cheapest – but is forbidden
by the FDA with an unacceptable complication rate
of around 25%.
● Intravariceal – causes thrombosis
● Paravariceal – causes tamponade and submucosal
fibrosis
26.
27. Mallory-Weiss tear
● Follows retching or any cause of
repeated elevation in intra-
abdominal pressure (even CPR).
● Longitudinal tear in distal
esophagus, stomach, or both.
● Mucosa and submucosa often
disrupted with intact muscularis
propria.
● 90% spontaneously stop bleeding.
● 1st – endoscopic therapy
● 2nd – gastrotomy with suture repair
28. Gastritis
● Small amount of
bleeding.
● Often seen in ICU
setting.
● Aim is to raise gastric
pH.
● Biopsy antrum for H.
pylori
30. Neoplasia
GIST
● GISTs – incidence 14 per
1 million
● If can excise with 1 cm
margin, then do it +/-
imatinib
● If cannot excise with
margins → imatinib →
reassess
● Don’t need LNs
● Stop any bleeding with
endoscopy if possible.
Others
● MALTomas – treat H.
pylori
● Hamartomas
● Hemangiomas
● Adenocarcinoma –
95% of gastric cancers
● When in doubt, cut it
out! Get LNs
33. Cameron Lesion
● Associated with 5-20%
of hiatal hernias
● Linear ulcerations most
often along the lesser
curve at the level of the
crura.
● Uncertain etiology.
● Treatment – PPIs and
surgical treatment of
hiatal hernia. Endoscopic
therapy for bleeding.
34. Dieulafoy’s Lesion
● AVM or vessel located in
submucosa.
● Etiology uncertain
● If bleeding – inject
epinephrine,
thermocoagulation, et al.
● Consider
angioembolization or
operative oversewing.
35. Hemobilia
● Ensure that blood is coming from the ampulla.
● Perform angiography with embolization
● After bleeding stops, treat underlying disorder.
36. Hemosuccus
Pancreaticus
● Pancreatitis or other pancreatic pathology causing
erosion into a vessel, frequently the splenic artery.
● Angiogram with embolization remains the treatment
of choice.
37. Aortoenteric Fistula
● Most often fatal.
● Herald bleed.
● Seen most often in
patient following graft
repair of an AAA.
● Look for para-aortic air
and contrast
extravasation on CT.
● Resect graft and perform
extra-anatomic bypass.
38. Duodenal Diverticula
● >90% are false diverticula
● Located on the pancreatic side of the 2nd and 3rd
portions of the duodenum
● Most common symptoms are abdominal pain and
bleeding.
● If asymptomatic, nothing to do.
● If bleeding, excise diverticulum or invert and close
defect.
