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UGI Bleed. Obie M. Powell, M.D. Joseph A. Iocono, M.D. Department of Surgery University of Kentucky. Mr. Mellenna. 57 year-old white male with recent history of dark stools presents to the emergency room complaining of a two hour history of vomiting blood and feeling faint.

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Ugi bleed

UGI Bleed

Obie M. Powell, M.D.

Joseph A. Iocono, M.D.

Department of Surgery

University of Kentucky


Mr mellenna
Mr. Mellenna

57 year-old white male with recent history of dark stools presents to the emergency room complaining of a two hour history of vomiting blood and feeling faint.

On presentation the patient is pale and lethargic complaining of abdominal pain.


History
History

What other points of the history do you want to know?


History mr mellenna
History, Mr. Mellenna

Characterization of symptoms

Temporal sequence

Alleviating / Exacerbating factors:

Pertinent PMH, ROS, MEDS.

Relevant family hx.

Associated signs and symptoms

Consider the Following


Characterization of symptoms
Characterization of Symptoms

Un-relenting nausea with associated burning epigastric discomfort

Pain is steady and rates it as a 5 on a scale of 1-10.


Temporal sequence
Temporal Sequence

Dark stools off and on for approximately 6 months.

Often has some mild epigastric pain to which he pays little attention. This pain has been occurring for the same duration.

Today he has been feeling “light headed” for about 3-4 hours, and has been throwing up blood for 2 hours.


Alleviating exacerbating factors
Alleviating / Exacerbating Factors

Standing erect worsens his light headedness and laying down improves it.

Nothing improves the pain or nausea

In the past eating food sometimes relieved his abdominal pain.


PMH

The patients past history is significant for

HTN

MI 3 years prior treated with angioplasty and stenting.

COPD

Osteoarthritis

No prior abdominal surgery


PMH

Medications

ASA - supposed to be on it but it bothers his stomach

Metoprolol 50mg po BID

Simvastatin 10mg po daily

Ibuprofen 400mg po QID prn, none in past 2 weeks

NKDA


Family social history
Family/Social History

Family History

Non-contributory

Social History

Married

Computer programmer

ETOH- 6 pack per week


ROS

As in HPI.

The patient denies chest pain, shortness of breath, fever, chills, anorexia, and dysuria

ROS should emphasize further characterization of the active disease process AND risk factors that may complicate surgery such as active infection, active CAD, poor exercise tolerance



Differential diagnosis
Differential Diagnosis

Esophageal varices

Gastric varices

Erosive gastritis

Mallory Weiss tear

Reflux esophagitis

Gastric malignancy

Vascular malformations

Nose bleed

Aorto-enteric fistula

Gastric ulcer

Duodenal ulcer

Consider the following


Physical exam
Physical Exam

What are you looking for?


Physical exam1
Physical Exam

What to look for

Vital signs: instability, respiratory distress, beware of beta blockade

Overall appearance: signs of anemia, dehydration

Abdominal exam: probe for peritonitis

Rectal exam: mandatory. Look for perianal causes of bleeding.


Physical exam mr mellenna
Physical Exam, Mr. Mellenna

Vital signs: Temp. 97.8, Pulse 90, BP 95/63 Resp. 30

Patient is alert and oriented. Pale skin and dry mucous membranes.

During your examination the patient has a large maroon bowel movement


Physical exam2
Physical Exam

Head is atraumatic / normocephalic, eyes sunken, pale conjunctiva

Neck- No lymphadenopathy, flat neck veins.

Oropharynx - dried blood, no active bleeding, dry mucus membranes.

CV- Regular rate and rhythm, no murmur, rubs, or gallops

Chest- Mild tachypnea, respirations are clear bilaterally no rales, rhonchi, or wheezes

Abdomen is scaphoid, soft, mildly tender in mid-epigastrum. Bowel sounds are present and hyperactive.

Extremities show no clubbing, cyanosis, or edema.

Rectal exam shows gross blood, enlarged smooth prostate, no palpable masses, no hemmorhoids or other peri-anal disease




Laboratory studies what is necessary
Laboratory studies: diagnosis?What is necessary?

Type and Cross

CBC: Do you expect anemia?

CMP: evaluate for hepatic dysfunction and renal compromise

Coags: active hemorrhage can cause coagulopathy and requires aggressive replacement

ABG: probe for acidosis


Laboratory values
Laboratory Values diagnosis?

10.2

55

140

110

11

144

108

31.1

1.1

4.3

20

ABG: 7.23 | 28 | 80 | 18 | -5

PT: 18 (1.5) PTT: 36

LFTs: Normal



Laboratory values discussion
Laboratory Values Discussion diagnosis?

An elevated BUN to Creatinine ratio can be a sign of upper GI bleed due to the digestion of blood or prerenal azotemia.

A patient actively hemorrhaging will show a normal Hgb/Hct prior to being resuscitated. Chronic bleeding presents with typical iron deficiency anemia.



Interventions to consider
Interventions to consider diagnosis?

ABC’s

Ensure adequate airway protection and adequate respirations

Start 2 large bore IV’s.

Fluid bolus either NS or LR

Foley Catheter

NG with gastric lavage

STAT Upper endoscopy


Endoscopy
Endoscopy diagnosis?

Upon upper endoscopy the esophagus appears normal.

There is a large amount of clot in the stomach, irrigation reveals normal appearing mucosa without signs of ulcer or gastritis.

On passing through the pylorus copious gross blood is encountered with a actively bleeding ulcer on the posterior wall of the duodenum.



Endoscopy1
Endoscopy diagnosis?

Attempt at injecting with epinepherine, and even direct pressure prove unsuccessful with continued brisk pulsatile bleeding.

Are there any particular endoscopic findings that suggest a higher risk of failed therapy or re-bleeding?


What would you do next
What would you do next? diagnosis?

Repeat Hct is 18

He is actively bleeding in Endoscopy


Surgery for bleeding ulcers
Surgery for Bleeding Ulcers diagnosis?

Indications

Pre-operative preparation

Operative approach

Relevant Anatomy

Potential complications


Operative indications
Operative Indications diagnosis?

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 passes just distal to the pylorus and posterior to the duodenum. If it or one of it’s branches are in the ulcer crater they may erode and result in massive bleeding.


Operative technique
Operative Technique diagnosis?

Patients are explored through an upper midline incision.

An incision is made in the anterior duodenum through the pylorus and distal stomach.

The site of bleeding is identified. The bleeding can then usually be controlled by placing sutures in 3-4 quadrants around the ulcer base.

The gastroduodenal artery may be ligated if necessary


Operative technique1
Operative Technique diagnosis?

Once bleeding has been controlled, the horizontal opening through the pyloric channel is closed vertically resulting in a Heineke-Mikulicz pyloroplasty.

A truncal vagotomy is then added for long-term ulcer control. Specimens of both vagal trunks are sent to Pathology to document the vagotomy


Gastrointestinal bleeding

Gastrointestinal Bleeding diagnosis?

Discussion


Gastrointestinal bleeding1
Gastrointestinal Bleeding diagnosis?

Bleeding can arise anywhere along the GI tract. Bleeding represents the initial symptom of gastrointestinal disease in 1/3 of all patients. The majority of bleeding will stop spontaneously.


Gastrointestinal bleeding2
Gastrointestinal Bleeding diagnosis?

Hematemesis- Vomiting of blood. Can be either gross blood and blood clots representing rapid bleeding or “coffee-ground” emesis signifying chronic bleeding. Hematemesis is the result of bleeding from the oropharynx to the ligament of Treitz.

Melena- Passage of black and tarry stool caused by digested blood.


Gastrointestinal bleeding3
Gastrointestinal Bleeding diagnosis?

Melena is usually the result of severe upper GI bleeding. Melena without hematemesis is caused by severe bleeding distal to the ligament of Treitz.

Hematochezia- Passage of maroon to red blood and blood clots.


Gastrointestinal bleeding4
Gastrointestinal Bleeding diagnosis?

As little as 50-60 mL of blood in the GI tract produces melena. Melena can persist from 5-7 days after a 2 unit bleed and stools can remain occult positive up to 3 weeks.

With upper GI blood loss blood urea nitrogen levels may be elevated to 30-50 mg/dL. A BUN: Creatinine ratio greater than 36:1 likely represents blood loss from an upper GI source.


Upper gastrointestinal bleeding
Upper Gastrointestinal Bleeding diagnosis?

Some dependency on socioeconomic factors. Peptic ulcers are more common in suburban hospitals, while gastritis and varices are more common in urban centers. Patients 60 years old and older represent ~ 60% of patients presenting with upper GI bleeding with a mortality rate of 20-25%. For younger patients the mortality rate drops to 4%.


Upper gastrointestinal bleeding1
Upper Gastrointestinal Bleeding diagnosis?

Although elective surgeries for duodenal ulcers have dropped off significantly due to H2 blockers and proton pump inhibitors, the number of surgeries for bleeding duodenal ulcers has remained stable.

Sudden cessation of H2 blockers or proton pump inhibitors may result in a rebound increase in acid secretion resulting in GI bleeding.


Upper gastrointestinal bleeding2
Upper Gastrointestinal Bleeding diagnosis?

Nose bleeds- Rarely the cause of major bleeding. It must be ruled out by a careful examination of the posterior pharynx to insure blood is not running down the esophagus, causing hematemesis .


Upper gastrointestinal bleeding3
Upper Gastrointestinal Bleeding diagnosis?

Esophagitis- Hiatus hernia and reflux esophagitis are not common causes of upper GI bleeding. Reflux esophagitis is more likely to result in chronic occult bleeding usually associated with grade II-III esophagitis with friable mucosa. Significant bleeding in this area is more commonly associated with para- esophageal hernias.


Upper gastrointestinal bleeding4
Upper Gastrointestinal Bleeding diagnosis?

Varices- Bleeding esophageal and gastric varices in the presence of liver disease account for about 10% of upper GI bleeds and are life threatening situations associated with a high mortality rate. Alcoholism is the most common cause of portal hypertension but hepatitis B and C are becoming common causes.


Upper gastrointestinal bleeding5
Upper Gastrointestinal Bleeding diagnosis?

Varices- In pediatric patients 95% of all upper GI bleeds are caused by variceal hemorrhage, usually as a consequence of extra hepatic portal venous obstruction. In patients with cirrhosis and portal hypertension variceal hemorrhage accounts for 50-75% of all upper GI bleeds. Variceal hemorrhage is usually precipitated by ulceration of the varix secondary to reflux esophagitis or increased pressure within the varix.


Upper gastrointestinal bleeding6
Upper Gastrointestinal Bleeding diagnosis?

Varices- In patients with liver disease bleeding is precipitated by the inability of the liver to synthesize clotting factors. Initial therapy includes sclerotherapy, ligation and vasopressin. Ligation is as effective as sclerotherapy with fewer complications. If unsuccessful shunting or transplant may be necessary.


Upper gastrointestinal bleeding7
Upper Gastrointestinal Bleeding diagnosis?

Mucosal tear (Mallory-Weiss)

Esophagogastric mucosal tear or Mallory-Weiss tear account for 5-10% of all upper GI bleeds. Mallory-Weiss tears present in a classic pattern. Initially the patient has vomiting without blood. Continued emesis leads to pain from the tear and eventually the patient develops hematemesis. 90% of Mallory-Weiss bleeding resolves spontaneously and require no further therapy.

If bleeding persists, endoscopic therapy with injection of vasoconstrictive agents, IV vasopressin or balloon tamponade with Sengstaken-Blakemoore tube may be necessary.


Upper gastrointestinal bleeding8
Upper Gastrointestinal Bleeding diagnosis?

Gastritis

Up to 1/3 of upper GI bleeds are caused by 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, while more brisk bleeding is usually a result of ingested substances harmful to the gastric mucosa such as NSAIDs, alcohol, steroids, or other drugs.

Treatment is with vasopressin, iced saline lavage, sucralfate, H2 blockers, and proton pump inhibitors. Bleeds refractory to these treatments may require electrocautery, vagotomy and antrectomy or even total gastrectomy.


Upper gastrointestinal bleeding9
Upper Gastrointestinal Bleeding diagnosis?

Peptic ulcer

Most common cause of upper GI bleed, encompassing 1/2- 2/3 of patients. Bleeding is presenting symptom in up to 10% of these patients. 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% of peptic ulcers and surgical intervention is needed in 20% of these patients


Upper gastrointestinal bleeding10
Upper Gastrointestinal Bleeding diagnosis?

Stress ulcers

Stress ulcers refer to acute gastroduodenal lesions that arise after episodes of shock, sepsis, surgery, trauma, burns (Curling’s ulcer), or intracrainial pathology or surgery (Cushing’s ulcer). Specific risk factors associated with these ulcers are, multi system trauma, hypotension, respiratory failure, sepsis, jaundice, recent surgery and burns.

It is believed that stress ulceration is 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 in the formation of stress ulcers.


Upper gastrointestinal bleeding11
Upper Gastrointestinal Bleeding diagnosis?

Other causes

Miscellaneous causes may contribute up to 18% of upper GI bleeds. Gastric neoplasms both malignant and benign can cause bleeding which is usually mild and chronic. Dieulafoy’s vascular malformations are dilated arterial lesions usually amendable to endoscopic injection.

Aorto-enteric fistulas can present as a herald bleed followed by a massive bleed in patients with prior aortic reconstructions. Hematobilia can be found in patients following hepatic injuries or manipulations.


Upper gastrointestinal bleeding12
Upper Gastrointestinal Bleeding diagnosis?

Management- Complete history with inquiries of peptic ulcer disease, alcohol use, cirrhosis, heart burn, reflux, and medications. Exam looking for signs of cirrhosis including spider angiomata, palmer erythema, prominent abdominal veins, caput medusa, and ascites. Examine mucous membranes for melanin spots associated with Puetz-Jeghers syndrome. Perform rectal exam and check for occult blood in the stool.


Upper gastrointestinal bleeding13
Upper Gastrointestinal Bleeding diagnosis?

Management- Fluid resuscitation, foley, naso-gastric tube, gastric lavage and arterial line.

Labs- Complete blood count with platelets, comprehensive metabolic panel with liver functions, and coagulation studies. Cross match for blood transfusion.


Upper gastrointestinal bleeding14
Upper Gastrointestinal Bleeding diagnosis?

Studies/Treatment :

EGD with sclerotherapy or electrocautery, tagged red blood cell scan, arteriography with embolization.

If esophageal bleeding does not respond to sclerotherapy, ligation, or intravenous vasopressin, Sengstaken-Blakemoore tube should be used.


Upper gastrointestinal bleeding15
Upper Gastrointestinal Bleeding diagnosis?

TIPS- for portal hypertension

Trans jugular intrahepaticporto-systemic shunt. Used for bleeding secondary to portal hypertension. Associated with in hospital mortality rate of 35-56%. Encephalopathy rate is the same as for patients who undergo porto-caval shunts. Stenosis or occlusion of TIPS is up to 50% at one year.


Lower gastrointestinal bleeding
Lower Gastrointestinal Bleeding diagnosis?

Small Bowel- Small bowel accounts for 10-15% of all lower GI bleeds. Usually a diagnosis of exclusion. Seeing blood exiting the ileo-cecal valve accounts for 10% of diagnoses. Causes include, Meckel’sdiverticulum, Crohn’s disease, intussusception, neoplasm, vascular malformations, intestinal varices, blood dyscrasias, non-Meckel’sdiverticulum, mesenteric thrombosis, drug reactions, enteric infections, and polyps.


Lower gastrointestinal bleeding1
Lower Gastrointestinal Bleeding diagnosis?

Colon- Most often related to polyps or neoplastic disease (occult). Right sided lesions usually present through anemia and guaiac positive stools. Larger bleeds can arise from diverticuli or angiodysplastic lesions on either the right or left side.


Lower gastrointestinal bleeding2
Lower Gastrointestinal Bleeding diagnosis?

Angiodysplastic lesions have the following characteristics. They are not congenital or neoplastic but degenerative. They are not associated with other vascular lesions. They increase with age. They are usually small < 5mm. They can be diagnosed by colonoscopy. 80% of angiodysplastic bleeds will stop spontaneously and 50% will re- bleed within 3 years.

Ulcerative colitis- Usually cause chronic bloody diarrhea, but massive bleeds can occur


Lower gastrointestinal bleeding3
Lower Gastrointestinal Bleeding diagnosis?

Management- Complete H&P. Fluid resuscitation, foley, naso-gastric tube, gastric lavage and arterial line.

Labs- Complete blood count with platelets, comprehensive metabolic panel with liver functions, and coagulation studies. Cross match for blood transfusion.


Lower gastrointestinal bleeding4
Lower Gastrointestinal Bleeding diagnosis?

Studies/Treatment:

Normalize coagulation. Colonoscopy, tagged red blood cell scan 91% sensitive and 100% specific. Angiography with or without coil embolization.

Local resection of defined bleeds, otherwise if bleeding continues and no source can be identified within the colon, total colectomy is indicated.


Rectal and anal bleeding
Rectal and Anal Bleeding diagnosis?

Fresh red blood on the exterior of stool usually represents hemorrhoids, fissures, or proctitis. Bleeding that drops into the toilet water is most likely the result of fissures or hemorrhoids. All rectal bleeding should be fully investigated with full H&P, anoscopy / proctoscopy and if necessary exam under anesthesia.


Questions
QUESTIONS ?????? diagnosis?


Acknowledgment diagnosis?

The preceding educational materials were made available through theASSOCIATION FOR SURGICAL EDUCATION

In order to improve our educational materials wewelcome your comments/ suggestions at:

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