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Upper gastrointestinal bleeding is defined as bleeding derived from a source proximal to the ligament of Treitz. Acute upper gastrointestinal bleeding is a potentially life-threatening abdominal emergency
The incidence of upper gastrointestinal bleeding (UGIB) is approximately 0.1 % of the general population.
Bleeding from the upper GI tract is approximately 4 times as common as bleeding from the lower GI tract and is a major cause of morbidity and mortality.
The use of various endoscopic techniques, medical therapies, and visceral angiography has progressively diminished the role of surgery in the emergent management of UGIB
Nevertheless, operative intervention still represents the most definitive intervention and remains the final therapeutic option for many bleeding lesions of the upper GI tract.
Of patients who develop UGIB, 3-15% requires a surgical procedure.
Hematemesis and melena are the most common presentations of acute UGIB, and patients may present with both symptoms.
Occasionally, a brisk upper gastrointestinal bleeding manifests as hematochezia.
In order of frequency:
Symptoms 30 days prior to admission
The history findings can be extremely helpful in determining the location of the GI hemorrhage.
Alcohol abuse or a history of cirrhosis should elicit consideration of portal gastropathy or esophageal varices
A history of recent nonsteroidal anti-inflammatory drug (NSAID) abuse -a gastric ulcer or chronic back –pain –the need for NSAIDs
History of treatment for Peptic ulcers-bleeding could be peptic ulcer disease or gastric ulcers.
Resuscitation of a hemodynamically unstable patient begins with assessing and addressing the ABCs (ie, airway, breathing, circulation) of initial management.
The earliest opportunity is taken to intubate the patient and avoid the risk of aspiration.
Using two large-bore venous access in the antecubital fossa. Replace blood loss with crystalloid in the ration of 1 ml of blood loss replaced by 3ml of crystalloid.
A urethral catheter for monitoring urine production.
Continuously monitor the resuscitation measures especially the circulatory aspect:
Urine output should be 30-50ml/hr
BP monitoring systolic BP not <90mmHg
A decrease in BP and urine output suggest the need for colloids but a decrease in urine output but normal BP suggest need for crystalloids
Pulse. The pulse should be less than 120/minute
CVP monitoring the best to avoid over-infusion
State of the patient should be calm
Once the maneuvers to resuscitate are underway, insert a nasogastric tube (NGT) and perform an aspirate and lavage procedure.
This should be the first procedure performed to determine whether the GI bleeding is emanating from above or below the ligament of Treitz.
If the stomach contains bile but no blood, upper gastrointestinal bleeding is less likely. If the aspirate reveals clear gastric fluid, a duodenal site of bleeding may still be possible
Endoscopy is both diagnostic and therapeutic for upper gastrointestinal bleeding.
Endoscopy should be performed immediately after endotracheal intubation (if indicated) and hemodynamic
Endoscopy is now the method of choice for controlling active ulcer hemorrhage and variceal bleeds.
Methods for hemostasis.
1) Injection of vasoactive agents
2) Injection of sclerosing agents
4) Band ligation
5) Pressure tamponade –with Constant probe
6) Application of hemostatic materials, including biologic glue
The 3 most popular methods of hemostasis are injection therapy, coaptive coagulation, and laser phototherapy
a)Epinephrine -diluted (1:10,000) and injected as 0.5- to 1-mL aliquots. Works by inducing vasoconstriction and decreasing blood flow to the area.
This allows for increased platelet function and clot formation to attain hemostasis.
However, the tamponade effect produced by injecting the volume of the drug into the tissue surrounding the bleeding lesion may also facilitate hemostasis.
b) Injecting a volume of sterile isotonic sodium chloride solution and providing a tamponade effect also leads to hemostasis, although not as effectively as epinephrine
The sclerosant solutions used today include
Sodium tetradecyl sulfate.
These achieve hemostasis by inducing thrombosis, tissue necrosis, and inflammation at the site of injection.
When large volumes are injected, the area of tissue necrosis can produce an increased risk of local complications such as perforation.
Uses direct pressure and thermal therapy to achieve hemostasis.
Thermal therapy includes monopolar and bipolar electrocoagulation and heater-probe application.
The bleeding vessel is isolated, compressed, and tamponaded prior to coagulation therapy. By using both maneuvers, the depth of tissue injury is minimized.
Coaptive coagulation is as effective as injection therapy in achieving hemostasis
Combining injection therapy with heater-probe coagulation can be used in an attempt to reduce the rebleeding rate in high-risk patients who have spurting arterial bleeding observed during endoscopy
Other aspects of treatment
Proton pump inhibitors decrease rebleeding rates in patients with bleeding ulcers associated with an overlying clot or visible nonbleeding vessel in the base of the ulcer. It is administered at the same time as endoscopy.
The indications for surgery in patients with bleeding peptic ulcers are as follows:
1) Severe life-threatening hemorrhage not responsive to resuscitative efforts
2) Failure of medical therapy and endoscopic hemostasis with persistent recurrent bleeding
3) A coexisting reason for surgery such as perforation, obstruction, or malignancy
4) Prolonged bleeding with loss of 50% or more of the patient’s blood volume
5) A second hospitalization for peptic ulcer hemorrhage
The 3 most common operations performed for a bleeding duodenal ulcer are as follows
a)Truncal vagotomy and pyloroplasty with suture ligation of the bleeding ulcer
c)Truncal vagotomy and antrectomy with resection or suture ligation of the bleeding ulcer
d)Proximal (highly selective) gastric vagotomy with duodenostomy and suture ligation of the bleeding ulcer
The 3 most common complications of a gastric ulcer that surgical intervention is hemorrhage, perforation, and obstruction.
The goals of surgery are to correct the underlying emergent problem, prevent recurrent bleeding or ulceration, and exclude malignancy.
A bleeding gastric ulcer is most commonly managed by a distal gastrectomy that includes the ulcer with a gastroduodenostomy or a gastrojejunostomy reconstruction.
The common operations for the management of a bleeding gastric ulcer include
(1) truncal vagotomy and pyloroplasty with a wedge resection of the ulcer
(2) antrectomy with wedge excision of the proximal ulcer, (3) Distal gastrectomy to include the ulcer with or without truncal vagotomy
(4) Wedge resection of the ulcer only.
The choice of operation type of ulcer and hemodynamic stability of the patient to withstand an operation.
Five types of gastric ulcers occur, based on their location and acid-secretory status.
Type 1 gastric ulcers are located on the lesser curvature of Are not associated with a hypersecretory acid state.
Type 2 ulcers represent a combination of 2 ulcers that are associated with a hypersecretory acid state. The 1st ulcer in the body of the stomach, 2nd ulcer in the duodenum.
Type 3 ulcers are prepyloric ulcers. They are associated with high acid output and are usually within 3 cm of the pylorus.
Type 4 ulcers are located high on the lesser curvature of the stomach and (as with type 1 ulcers) are not associated with high acid output.
Type 5 ulcers are related to the ingestion of NSAIDs or aspirin. These ulcers can occur anywhere in the stomach.
A vagotomy is added to manage type 2 or type 3 gastric ulcers.
The patient with acute variceal bleeding may initially be treated with; intravenous vasopressin and nitroglycerine somatostatin, or one of its analogs (eg, octreotide).
Vasopressin is a potent splanchnic and systemic vasoconstrictor, including coronary vasoconstriction. Nitroglycerin should be concomitantly administered to titrate and maintain the SBP in the range of 90-100 mm Hg. Nitroglycerin should be initiated at 40 mcg/min to protect the coronary arteries from the profound adverse cardiovascular effects of the vasopressin. The intravenous infusion of vasopressin is started at 0.2-0.4 U/min.
The 2 main endoscopic techniques available to control variceal bleeding are endoscopic sclerotherapy and endoscopic variceal band ligation.
Endoscopic sclerotherapy involves injecting a sclerosing agent, such as ethanolamine or polidocanol, into the varix lumen (intravariceal) or immediately adjacent to the vessel (paravariceal) to create fibrosis in the mucosa overlying the varix, which leads to hemostasis.
Endoscopic variceal banding ligation consists of the placement of a rubber band around the varix. This technique is performed by first sucking varix into a sheath attached to the distal end of the endoscope. Once the varix is suctioned into the sheath, a trigger device allows the deployment of a rubber band around the varix, a procedure that strangulates varix.
Variceal banding associated with significantly lower mortality rates, lower variceal rebleeding, less esophageal perforation, and stricture formation compared to sclerosants
It can be a life-saving maneuver when medical and endoscopic efforts fail to control the bleeding. Achieve temporary control of the bleeding but recurrent bleeding with the release of the tamponade occurs in most patients
They also cause complications as
esophageal necrosis with rupture
Because of the severe life-threatening complications and limited use, the tubes are used only as a temporary measure while the patient is resuscitated.
The tubes act as a bridge to help stabilize the patient until a time when the patient is prepared for either a repeat endoscopy procedure or a portal pressure decompression through a radiological or surgical method
The 2 most commonly used tubes are the Sengstaken-Blakemore tube and the Minnesota tube. These tubes have an esophageal balloon and a gastric balloon that is inflated to produce a tamponade effect after confirming appropriate anatomical placement.
Before use endotracheal intubation to secure and protect the patient’s airway
1) Esophageal rupture
2) Tracheal rupture
3) Duodenal rupture
4) Respiratory tract obstruction
7) Tracheoesophageal fistula
8) Jejunal rupture
9) Thoracic lymph duct obstruction
10) Esophageal necrosis
11) Esophageal ulcer
1) Nasopharyngeal bleeding
2) Chest pain
3) Balloon impaction and/or migration (nausea and vomiting)
4) Alar necrosis
The tube is first introduced into the stomach, and a small amount of air is injected into the gastric balloon. A radiograph is then obtained to confirm placement in the stomach. Once proper placement is confirmed, the gastric balloon is inflated with 300-350 mL of air and is pulled up into the gastric fundus, compressing the gastroesophageal junction.
The tube is secured to the facemask of a football helmet placed on the patient’s head. The esophageal balloon is then inflated to a pressure of 40 mm Hg. Another radiograph is obtained to confirm the proper placement of both tubes.
Deflate the esophageal balloon every 4 hours for 15 minutes to avoid esophageal pressure necrosis.
Do not leave the entire tube in place for more than 24-48 hours.
Transjugular intrahepatic portosystemic shunt (TIPS) decompression of the portal system can be achieved through either radiologic or surgical methods. The goal is to reduce intravariceal pressure to less than 12 mm Hg. The TIPS procedure for bleeding esophagogastric varices that are unresponsive to endoscopic and pharmacologic first-line treatment
By surgery -Portacaval shunt (end-to-side) or (side-to-side)