RARE CAUSES OF MASSIVE HEMATEMESIS AND MELAENA

KURDISTAN GIT CENTER Sulaimany Department

November - 2006

Case PresentationCase No.1Tanka Nasih 20 years old female from chamchamal/ Suleimania presented with massive hematemesis and malena. Receiving 30 pints of blood four times has been scoped without diagnosis.We received her in Shorish military hospital in Suleimanya Kurdistan Regional Government / Iraq.It has been observed that she was mildly jaundiced. BP systole 30mmHg. Weak pulse PR 140 /m regular. Deadly pale, mild abdominal tenderness , no guarding, increase bowel sounds, no organomegaly. Other system has no thing to be mentioned apart from oliguria.Investigations has been ordered after very quick resuscitation of the patient with proper urine out put. GUE bile pigment +ve urobilinogen present.PCV 20%WBC 12,000 /mlESR 35 mm /hrBU 80 mg /dlB. Group/ B+B. sugar 110 mg/ dlElectrolyte, acid base were not available.TSB 4mg/dl mainly direct.SAP 18 KAUCoagulation profile was not available apart from bleeding and clotting time which were normal.Chest XR normal.ECG inconclusive.Serum amylase not available.Angiography not available.CT not done because she was unstable.Upper GIT scope revealed hemobilia. The procedure took 30 min.

US was unfortunately inconclusive. Our hand has been forced into explore her immediately and the exploration revealed obviously dilated bile ducts and discolored more or less black. The duct has been explored in supra duodenal portion after kokherization of the duodenum and after been sure of no other pathology in the upper abdomen. The blood was gushing out in clots obscuring the view. The assistant expert surgeon has immediately used the Pringle maneuver smoothly controlling the situation, then the search has been started for the source of the bleeding by this way.Inserting the Folley's catheter in the lower duct inflating the ball then removing the Pringle's maneuver the bleeding was still the same. Then the process has been repeated in the upper tree, first in the right and then in the left, the bleeding was still the same amount. This situation raised in our mind two possibilities:The bleeding coming from a third duct ( Triforcation)It is coming from the confluence or little downward.The exploration has been extended up revealed a convoluted soft swelling inside a hole of about 0.75 cm in diameter. It has been identified as a cause of bleeding. It has been underrun with polydioxanone suture by few figure 8 methods, there was still little bleeding which has made us to ligate the right hepatic artery. Which resulted in complete cessation of bleeding.

Biliary tree has been gently washed out and a T- tube was inserted with a drain after cholecystectomy. The recovery was uneventful and the patient has been send to ICU.Then postoperative antibiotic, vitamin K, and fresh blood transfusion with supportive treatment and general intensive care monitoring has been applied.She has been discharged from the hospital two weeks later.Date of Admission: 2/6/2000 Date of Discharge: 16/6/2000.Histopathology of the free tissue from the convoluted swelling revealed abnormal dilated vascular structures. Conclusion:- The diagnosis is ruptured A-V malformation of the bile duct. Proper preoperative localization of bleeding and even non bleeding lesions of the liver by all means of technology is mandatory for successful surgery . But if they are not available, our method which has been used for intra operative localization has been beneficial. Hard days may not stop surgeons performance and tissue appeal will lead you what to do in difficult circumstances.

BLEEDING AV MALFORMATION AT THE BIFURCATION OF THE BILE DUCT

THIS IS THE POSTERIOR WALL BECAUSE THE BILE DUCT HAS BEEN OPENED ANTERIORLY LIKE OPEN BOOK

A FOLEY CATHETER IN THE LEFT DUCT 16 CHARRIERE

A FOLEY CATHETER IN THE RIGHT DUCT

THE BLEEDING HAS BEEN CONTROLLED BY PRINGLES MANOUEVRE

THE BLEEDING STARTED AGAIN AFTER REMOVAL OF THE PRINGLES MANOUEVRE

THE NOZLE OF THE SUCKER IN THE RAPTURED AV MALFORMATION

Case No.2Sadia Ahmed 23 years old female from Chamchamal / Suleimania / Kurdistan Government Iraq. Presented with hematemesis and malena to Shorish military hospital. Recurrent in nature, moderate in amount. Receiving over all 12 pints of blood in a course of one month. Many times scoped in Baghdad and undiagnosed.US revealed 5 cm echogenic lesion, round shape in the right lobe of the liver, deeply seated. At the time of admission she was shocked, rapid circulatory support has performed by blood transfusion and then scoped which revealed hemobilia. The procedure took 35 min. PCV 22%WBC 8000/mlESR 60mm/hr.GUE inconclusive BU 55 mg/dlSerum amylase not available.Electrolyte, cid base and blood gas not available.Coagulation profile was not available apart from bleeding and clotting time both of which were normal.Liver function shows mild increase in TSB 3mg/dl and mildly raised Alkaline phosphatase 17 KAUAngiography was not available. And the CT has not been done because of the unstability of the patient's condition.Blood group A+ Chest XR and ECG were normal .No other investigation were available in that small hospital in hard days of Saddam's Erra. Exploration was urgent and done by Kokher incision the bile duct has been seen dilated with greenish color. It has been explored and the blood was evacuated . Pringles maneuvers has been applied and follys catheter ball has been used to localize the site of the bleeding as the first case and the lesion has been located in the upper biliary tree. Segmental resection of the segment 6 of the liver was done depending on palpation of the firm lesion. The biliary tree has been cleaned and the duct has been closed on T- tube. She had uneventful recovery. Discharged 10 days later. After 3 weeks of the initial surgery she had the same presentation of upper GIT bleeding, the scope again revealed hemobilia. She has been explored again after resuscitation and the firmness was extending to the wider area of the right lobe involving segment 5. The blood was coming from both ducts even after repeated wash out. Longitudinal gauze pack has been inserted repeatedly to both ducts, the result was not very conclusive because both biliary tree were full of blood and it was difficult to clear them completely. It made us in a mess. We has been obliged to do right hepatic lobectomy by thoraco-abdominal incision due to difficulties in the area made by the previous surgery. There was no way to locate the source except by palpation. Which revealed indurations in the right lobe with almost normal consistency of the left lobe. On this base of the operative decision was right hepatic lobectomy. Fortunately she had uneventful recovery and the histopathology was consitent mostly with amoebic liver abscesse.Date of Admission 5/9/2001Date of Discharge 15/9/2001. Conclusion:- Case No. 2 Liver abscesse is common in Kurdistan , specially amoebic liver abscesse . Only this case has been reported as bleeding one . Preoperative localization by technology is mandatory but if they are not available the same method of the first case can be used successfully. And for hemobilia the best incision is kokher which could be changed to roof- top incision if it is necessary in the operation for biliary tree.

Sa’adia /intrabiliary bleedingAmoebic liver abscess

54 years lady house wife .presented with haematemesis and melaena and abdominal pain with mild jaundice ,she was in a state of schok,for which resuscitation was done, and the history was all of a sudden , one day duration and urgent upper G I T endoscopy has been done ,obviously the bleeding was coming from the major duodenal papilla .and the diagnosis of hemobilia has been done. Diagnostic work up was done and the slides are provided .

Blood count was showing anaemia ESR was 70 mm/hour ,wbc was 10000/cm3.

Total serum bilirubine was 5mg%ml and alkaline phosphatase was triple of normal .other biochemical tests was.

Serum electrolyte /normal

Blood gas analysis were not available

Other positive findings were as follow

Ultra sound / mass at porta hepatis and normal bile duct ,multiple gall stones

C T /has been provided as slides

MRCP /not available

E R C P was clearly showing a narrowing at upper bile duct ,and dilated lower bile duct .the pressure from out side on the upper part of the common duct was clear.

Angiography was not available .

EXPLORATION /was done after 24 hours by ROOF TOP incision

There was very thick wall gall bladder which was tense and hard ,there was a swelling ( abscess ) in the quadrate lobe. The gall bladder was opened and it was full of clots and many impacted stones, all were evacuated and gush of blood was coming from the gall bladder ,which was opened and it was typical

( MIRIZZI ) syndrome .The bile duct was opened already ,and SUBTOTAL cholecystectomy was done ,then intero external drainage was done and the remnant of gall bladder was sutured on the tube .she had un eventful recovery.

21/12/2008 shorish hospital kurdstan regional government/sulaimany/Iraq

BLOOD COMING FROM THE MAJOR DOUDENAL PAPILLA

GUSH OF BLOOD AND STONES COMING OUT FROM THE OPENED GALL BLADDER

AFTER OPENING THE GALL BLADDER ,A GUSH OF BLLEDING IS VERY OBVIOUS HERE

BILE DUCT OPENED

LOWER END OF BILE DUCT

A CURVED ARTERY FORCEPS WAS PASSED TO THE RIGHT DUCT THEN TO THE LEFT.WE ARE AT THE BIFURCATION

GALL STONES AND THEIR RESULT …..CLOTS WHICH WRE EXTRACTED FROM THE GALL BLADDER.

Case number IV

60 years old male ( farmer ),presented with massive haematemesis and melaena .resuscitation was done ,and emergency upper ( GIT ) endoscopy was done, and unfortunately there was a duodenal ulcer in the bulb and the interpretation was bleeding duodenal ulcer ,and argon plasma coagulator was done on and around the ulcer .but still the patient was bleeding after that attempt profusely .and he had intered into a shock state again .Resuscitation has been done again .and he became stable .review of his history the condition has started several days after upper abdominal pain which was sever and he consulted at night for some injections for his pain .which has been almost relived after several hours ,past medical or surgical history was not conclusive and so the review of his systems . Basic investigations was normal apart from anaemia and mild leukocytosis .Ultra sound was not conclusive ,and so his emergency cotrast C T scan was not conclusive too.

Angiography was not available ,liver function showed bilirubine ,1.5 mg%ml and almost normal other parameters .

We explored him on the base of second massive bleeding in this age and the cause was not obviously evident .

At laparotomy there was a mass in the second part of the duodenum which was adherent to the liver and gall bladder bed then mobilization has been done and the mass was gall bladder which was opened to the duodenum at the second part posteriorly ad profusly bleeding inside the viscous ,the gall bladder was perforating the liver bed at the segment 5 area and most of the bleeding was coming from the necrotic liver bed .the bledin was controlled by under run figure 8 suture and cholecystectomy was done ,the doudenum was closed by single layer polydioxanone suture in a lazy s manner to prevent stenosis.The gall stone has been found in the sigmoid colon and the extracted later during digital rectal examination .the pictures of the colonoscope which was done later after surgery has been taken by mobile phone camera on the video station screen .It has been provided as slides . The patient had n evetful recovery apart from some reflux symptomes which was mild and ignored by the patient.

dr Qalandar

consultant surgeon ,chairman GI center/ kurdistan regional government/ Iraq

sulaimany teaching hospital 8/2008.

dr Rajan specialist surgeon GI center

dr Fazladin G I center specialist surgeon

The gall stone seen inside the sigmoid colon with obvious blood inside the lumen

The stone after removal by digital rectal exam ,the blood is frank on the index finger

The stone is showing its

size

Blood and bile ,both are seen here with the stone

THE GALL STONE AFTER WASHING IN A DISH