1. University of Kentucky
UGI Bleed
Obie M. Powell, M.D.
Joseph A. Iocono, M.D.
Department of Surgery
University of Kentucky

2. 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.

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

4. History, Mr. Mellenna Consider the Following
Characterization of symptoms
Temporal sequence
Alleviating / Exacerbating factors:
Pertinent PMH, ROS, MEDS.
Relevant family hx.
Associated signs and symptoms

5. 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.

6. 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.

7. 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.

8. PMH HTN MI 3 years prior treated with angioplasty and stenting. COPD
The patients past history is significant for
HTN
MI 3 years prior treated with angioplasty and stenting.
COPD
Osteoarthritis
No prior abdominal surgery

9. 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

10. Family/Social History
Family History
Non-contributory
Social History
Married
Computer programmer
ETOH- 6 pack per week
Family History
Non contributory
Social History
Married, computer programmer
ETOH—6 pack per week

11. 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

12. What is your Differential Diagnosis?

13. Differential Diagnosis
Consider the following
Esophageal varices
Gastric varices
Erosive gastritis
Mallory Weiss tear
Reflux esophagitis
Gastric malignancy
Vascular malformations
Nose bleed
Aorto-enteric fistula
Gastric ulcer
Duodenal ulcer

14. Physical Exam
What are you looking for?

15. 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.

16. 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

17. 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

18. Would you like to revise your initial differential diagnosis?

19. What Labs do you need ?

20. Laboratory studies: 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

21. Laboratory Values ABG: 7.23 | 28 | 80 | 18 | -5 PT: 18 (1.5) PTT: 36
10.2 55
140
110 11
144
108
31.1
1.1
4.3 20
ABG: | 28 | 80 | 18 | -5
PT: 18 (1.5) PTT: 36
LFTs: Normal

22. What do you think about the labs?

23. Laboratory Values Discussion
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.

24. What would you do now?

25. Interventions to consider
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

26. Endoscopy 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.

27. What would you do now?

28. Endoscopy
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?

29. What would you do next? Repeat Hct is 18
He is actively bleeding in Endoscopy

30. Surgery for Bleeding Ulcers
Indications
Pre-operative preparation
Operative approach
Relevant Anatomy
Potential complications

31. Operative Indications
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.

32. Operative Technique
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

33. Operative Technique
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

34. Gastrointestinal Bleeding
Discussion

35. Gastrointestinal Bleeding
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.

36. Gastrointestinal Bleeding
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.

37. Gastrointestinal Bleeding
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.

38. Gastrointestinal Bleeding
As little as 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 mg/dL. A BUN: Creatinine ratio greater than 36:1 likely represents blood loss from an upper GI source.

39. Upper Gastrointestinal Bleeding
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%.

40. Upper Gastrointestinal Bleeding
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.

41. Upper Gastrointestinal Bleeding
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 .

42. Upper Gastrointestinal Bleeding
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.

43. Upper Gastrointestinal Bleeding
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.

44. Upper Gastrointestinal Bleeding
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.

45. Upper Gastrointestinal Bleeding
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.

46. Upper Gastrointestinal Bleeding
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.

47. Upper Gastrointestinal Bleeding
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.

48. Upper Gastrointestinal Bleeding
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

49. Upper Gastrointestinal Bleeding
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.

50. Upper Gastrointestinal Bleeding
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.

51. Upper Gastrointestinal Bleeding
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.

52. Upper Gastrointestinal Bleeding
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.

53. Upper Gastrointestinal Bleeding
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.

54. Upper Gastrointestinal Bleeding
TIPS- for portal hypertension
Trans jugular intrahepatic porto-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.

55. Lower Gastrointestinal Bleeding
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’s diverticulum, Crohn’s disease, intussusception, neoplasm, vascular malformations, intestinal varices, blood dyscrasias, non-Meckel’s diverticulum, mesenteric thrombosis, drug reactions, enteric infections, and polyps.

56. Lower Gastrointestinal Bleeding
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.

57. Lower Gastrointestinal Bleeding
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

58. Lower Gastrointestinal Bleeding
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.

59. Lower Gastrointestinal Bleeding
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.

60. Rectal and Anal Bleeding
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.

61. QUESTIONS ??????

62. Acknowledgment
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