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GASTROINTESTINAL BLEEDING · PDF file gastrointestinal (GI) conditions and certain hepatobiliary and pancreatic disorders. Lower gastrointestinal bleeding (LGIB), defi ned as abnor-mal

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  • DOI 10.2310/7800.2064

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    gastrointestinal tract and abdomen

    G A S T R O I N T E S T I N A L B L E E D I N G

    Ezra N. Teitelbaum, MD, and Eric S. Hungness, MD, FACS

    Despite recent advances in therapeutic endoscopy and the widespread use of antisecretory medications, upper gastrointestinal bleeding (UGIB), defi ned as bleeding that occurs proximal to the ligament of Treitz, continues to be one of the more common reasons for surgical consultation. It also remains a signifi cant source of mortality for both emergency admissions (11%) and inpatients (33%).1 The most common causes of UGIB are esophageal and gastric varices, Mallory-Weiss tears, acute hemorrhagic gastritis, gastric and duodenal ulcers, and neoplasms.1 Less common causes include various other gastrointestinal (GI) conditions and certain hepatobiliary and pancreatic disorders.

    Lower gastrointestinal bleeding (LGIB), defi ned as abnor- mal hemorrhage into the lumen of the bowel from a source distal to the ligament of Treitz, usually derives from the colon; however, the small bowel is identifi ed as the source of bleeding in as many as one third of cases.2 In as many as 11% of patients presenting with hematochezia, brisk UGIB is identifi ed as the source.3 The most common causes of LGIB are colonic, with diverticular disease being the most common and accounting for 30 to 40% of all cases.4 Arterio- venous malformations (AVMs), although extensively described in the literature, are considerably less common causes, accounting for 1 to 4% of cases.5 Other less common causes include infl ammatory bowel disease (IBD), benign and malignant neoplasms, ischemia, infectious colitis, benign anorectal disease, coagulopathy, use of nonsteroidal antiinfl ammatory drugs (NSAIDs), radiation proctitis, AIDS, and small bowel disorders.

    Presentation and Initial Management

    Gastrointestinal bleed- ing (GIB) may present as severe bleeding with hematemesis (UGIB), hema- tochezia (UGIB or LGIB), and/or symptoms of hy- potension or severe anemia (syncope, light-headedness, dyspnea, chest pain). UGIB may be gradual, presenting with melena, or occult, presenting with symptoms of chron- ic anemia (fatigue, dyspnea). The initial steps in the evalua- tion of patients with GIB are based on the perceived rate of bleeding and the degree of hemodynamic stability. Hemodynamically stable patients who show no evidence of active bleeding or comorbidities may be treated on an outpatient basis,6 whereas patients who show evidence

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    of serious bleeding should be managed aggressively and hospitalized.

    In the acute setting, the airway, breathing, and circulation should be rapidly assessed, and the examiner should note whether the patient has a history of or currently exhibits hematemesis, melena, or hematochezia. Blood should be sent to the blood bank for typing/crossmatching, complete blood count, blood chemistries (including tests of liver func- tion and renal function), and measurement of the prothrom- bin time and the partial thromboplastin time. If UGIB is suspected, the patient should be given an intravenous (IV) proton pump inhibitor (PPI) empirically (e.g., omeprazole 80 mg bolus dose followed by a 8 mg/hr continuous infu- sion in high-risk patients) as preendoscopy PPI administra- tion has been shown to decrease the need for endoscopic therapy for bleeding peptic ulcers.7,8

    If the patient is stable and shows no evidence of recent or active hemorrhage, the surgeon may proceed with the work- up. If the patient is unstable or shows evidence of recent or active bleeding, short, large-bore IV lines should be placed before the workup is begun to ensure that immediate IV access is possible should the patient subsequently become unstable. He or she should be taken to an intensive care unit and resuscitated immediately. Resuscitation of an unstable patient is begun by establishing a secure airway and ensur- ing adequate ventilation.9 Oxygen should be given, with a low threshold for endotracheal intubation. Much as in trauma resuscitation, either short, large-bore, peripheral IV lines or a single-lumen 8 French catheter in the femoral vein should then be placed, through which lactated Ringer solution or 0.9% normal saline should be infused at a rate high enough to maintain tissue perfusion. A urinary catheter should be inserted and urine output monitored. Blood prod- ucts should be given as necessary, and any coagulopathies should be corrected. Transfusion should aim at maintaining both a hemoglobin level of 7 g/dL or greater and adequate end-organ perfusion (as measured by urine output, mental status, etc.). It is all too easy to forget these basic steps in a desire to evaluate and manage massive GI hemorrhage.

    Every effort should be made to resuscitate and stabilize the patient suffi ciently to allow clinical evaluation and diag- nostic testing to help determine the cause of the bleeding and direct subsequent care. Only if the patient remains unstable and continues to bleed despite maximal supportive measures should he or she be taken to the operating room (OR) for intraoperative diagnosis.

    Clinical Evaluation

    Only after the initial measures to protect the airway and stabilize the patient have been completed should an attempt be made to establish the cause of the bleeding. The history should focus on known causes of GIB (e.g., previous GIB, peptic ulcer disease, diverticulosis, AVM, esophageal vari- ces, liver disease, alcohol abuse, and IBD) and on the possi- ble use of medications that interfere with coagulation (e.g.,

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    gastro gastrointestinal bleeding — 2

    Assessment and Management of Gastrointestinal Bleeding

    Perform initial assessment and management

    Patient presents with GI bleeding

    Manage UGIB source

    Gastric neoplasm

    Evaluate airway, breathing, and circulation.

    Look for past or current hematemesis, melena, or hematochezia.

    Draw blood for CBC, blood chemistries, measurement of PT and PTT, and typing and crossmatching.

    Acute hemorrhagic gastritis

    Stop NSAIDs. Give H2 receptor blockers, omeprazole, sucralfate, or antacids. Give anti–Helicobacter pylori therapy. If bleeding stops: observe. If bleeding continues: consider IV somatostatin (250 µg bolus, then 250 µg/hr) or intra-arterial vasopressin (10 U/hr). If this step is effective, observe; if not, perform total or near-total gastrectomy [search for

    astric and uodenal isease].

    Patient is stable

    Proceed with workup.

    If active bleeding is present: insert large-bore IV line before workup.

    Patient stabilizes

    Proceed with workup.

    Duodenal ulcer

    [See Figure 1.]

    Gastric ulcer

    [See Figure 1.] Gastric varices

    [See Figure 4.]

    Esophageal varices

    [See Figure 4.]

    Patient remains unstable

    Proceed to OR for intraoperative diagnosis and management.

    Lesion is benign

    Perform wedge excision of lesion.

    Lesion is malignant

    Attempt endoscopic control of bleeding.

    If bleeding stops: excise lesion electively.

    If bleeding continues: excise resectable lesions promptly; nonresectable lesions call for a nonoperative approach.

    Patient is unstable

    Give oxygen by mask or by ET tube and ventilator.

    Insert large-bore IV line, and infuse lactated Ringer solution.

    Insert urinary catheter, and monitor urine output.

    Give blood as needed.

    Correct any coagulopathies.

    Mallory-Weiss tear

    Lesion usually stops bleeding without therapy. If it does not, control bleeding endoscopically.

    If bleeding stops: observe.

    If bleeding continues: perform anterior gastrotomy with direct suture ligation of tear.

    the publication procedures for benign and malignant g d d

    Scientific American Surgery

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    gastro gastrointestinal bleeding — 3

    Hiatal hernia

    Manage LGIB source [See Figure 5.]

    Occult bleeding source

    Perform capsule endoscopy Perform double balloon enteroscopy.

    Paraesophageal hernia (type II–IV hiatal hernia)

    Sliding hernia (type I hiatal hernia)

    Repair surgically (either via open laparotomy or via minimally invasive approach) [search

    for open

    and minimally invasive sophageal rocedures].

    Duodenal diverticula

    Excise lesion, with or without the aid of intraoperative endoscopy.

    Give PPI and, if applicable, anti–H. pylori therapy.

    If bleeding stops: continue medical therapy.

    If bleeding continues: perform Nissen fundoplication [search the publication for open esophageal procedures and minimally invasive esophageal procedures].

    Hemobilia

    Perform arteriographic embolization of affected portion of liver.

    Other options are hepatic artery ligation and hepatic resection.

    Dieulafoy lesion

    Attempt endoscopic control. Mark site with India ink.

    If bleeding stops: observe.

    If bleeding continues: ligate or excise vessel.

    Aortoenteric fistula

    Resect aortic graft.

    Close enteric site of fistula.

    Place extra-anatomic or in situ arterial graft.

    Vascular ectasias

    Attempt endoscopic control of bleeding. Consider IV somatostatin (250 μg bolus, then 250 μg/hr). If bleeding stops: observe.

    If bleeding continues: resect lesion.

    Hemosuccus pancreaticus

    Pe

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