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Intraperitoneal & retroperitoneal haemorrhage. Complex ethiology any vascular lesion if big enough  Lesions of solid organs – Liver, spleen, kidney,

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Presentation on theme: "Intraperitoneal & retroperitoneal haemorrhage. Complex ethiology any vascular lesion if big enough  Lesions of solid organs – Liver, spleen, kidney,"— Presentation transcript:

1 Intraperitoneal & retroperitoneal haemorrhage

2 Complex ethiology any vascular lesion if big enough  Lesions of solid organs – Liver, spleen, kidney, pancreas  Lesions of hollow organs and mesentery  Lesions of parietal vessels (cirrhosis)  Genital lesions: extra uterine pregnancy  Fractures of vertebral column  Lesions of big retroperitoneal vessels (aorta, IVC, etc)  Postoperative  Many others

3 Symptoms  Hemorrhagic syndrome – Symptoms develop in hours – Cataclismic hemorrhage  Clinical presentations – Pale – Agitation, pseudo-psychotic manifestations – Hypotension – Oliguria/anuria

4 Abdominal evaluation  Inspection: may be enlarged, especially in massive haemorrhage  Sensibility: spontaneous and o palpation  Ausculation: intestinal sound may be diminished due to peritoneal irritation  Percution: – free liquid in the abdomen (movable dullness) – Increased liver or splenic dullness

5 Careful anamnesis: STRANGE SITUATION  Ectopic pregnancy – major cause of hemoperitoneum  Progression of a hematoma in sequences  Pelvic griddle and vertebral fractures can bleed in the free peritoneum  Iatrogenic lesions

6 Progression with a FREE INTERVAL  Trauma  Silent period – almost no symptoms – SUBCAPSULAR HEMATOMA will form in this time – Hematoma ruptures in the peritoneal cavity - hemoperitoneum

7 Lab work  Plain abdominal X-Ray  Abdominal US – Can demonstrate free liquid in the peritoneal cavity + specific character of blood – Can show lesions and abnormalities in the structure of solid organs – Can demonstrate pregnancy or signs associated with ectopic preganancy  Paracentesis + lavaj

8 Particular aspects of retroperitoneal hemorrhage  Frequently in the context of polytrauma  “No room” closed space –possible spontaneus hemostasis  Clinical forms – Small unnoticed hematoma – Large volume: “tumor like” appearance – Echimosis may appear due to blood migration

9 Special evaluation aiming for a retroperitoneal hematoma  US scan – special attention for kidney and large vessels  Intravenous urography  Rx for vertebral column and pelvic griddle  CT scan  Paracentesis + lavaj

10 Upper GI bleeding Syndrome Syndrome: GROUP of diseases which may be unrelated

11 Upper GI bleeding - definition  Internal hemorrhage becoming exteriorized  Hematemesis – above the angle of Treitz  Melena – above the ileo-cecal valve  Hematochesis (fresh blood per anum) – bellow splenic flexure  Hypovolemic shock – the only manifestation

12 Main causes  Duodenal ulcer24%  Erosive gastritis23%  Gastric ulcer21%  Esofageal varices10%  Esofagitis8%  Sdr. M-W7%  Erosive duodenitis6%  Tumors3% Large geographical variations

13 DIAGNOSTIC VS TREATAMENT  EMERGENCY  Urgent treatment should precede complete diagnostic  Sequence – Positive diagnostic - GI bleeding – Resuscitation – Empiric treatment – Ethologic diagnostic – Specific treatment

14 Homodynamic evaluation pulse + blood pressure  Shock – systemic blood pressure in decubitus <90mmHG – 50% din VC  No shock – BP and pulse checked in ortostatism – BP<90 lost = 25-50% – BP-10 or pulse >120/min = 20-25%

15 MONITOR PATIENTS - REBLEEDING MODELS  CONTINUOUS BLEEDING No response to treatment No major rebleeding Clinical observation = ESSENTIAL  MAJOR REBLEEDING EPISODE Sudden onset Most frequently in ICU Cases only with hypovolemic shock

16 Rebleeding – major prognostic factor  Definition: bleeding after a succesfull attempt to maintain hemodynamic stability  High mortality: 3x  3 major risk factors for morbidity and mortality  Major rebleeding in the hospital  Old age  Total amount of transfused blood

17 WHAT IS THE CAUSE?  Clinical evaluation  X-Ray and US scan  endoscopy “GOLD DIAGNOSTIC”

18 ANAMNESIS patient + relatives  Describe bleeding – Quantities can not be approximated  Other signs during or before onset  PMH – suggestive for a medical problem that may cause bleeding  Hereditary problems  Alcohol intake  False bleeding, false upper GI bleeding  Medication  Coughing before hematemesis  Mouth bleeding

19 CLINIICAL EVALUTATION  Hemodynamic evaluation  Confirm upper GI bleeding HEMATEMESIS, MELENA or RECTAL ENT evaluation.  Clinical signs suggestive for liver cirrhosis (liver and spleen size, ascites,colateral circulation, spider hemangioma,Dupuytren,etc)  Tumors  Other diseases that can produce GI bleeding

20 IMAGISTICS  Can be of major interest  Rx thorax Pleuresia Tuberculosis Primary or secundary tumors  US abdominal Liver cirrhosis Abdominal tumors  Barium meal Bad alternative when endoscopy is irrelevant

21 ENDOSCOPY  Establishes: SOURCE OR SOURCES OF BLEEDING  Evaluation of RISK OF REBLEEDING  THERAPEUTIC ACCES to lesion

22 FIRST LESION: “MIRAGE”

23 Esophageal causes  Varices  Mallory-Weiss  Hiatal hernia and reflux  Esophageal tumors

24 Varices  Endoscopic diagnosis can be difficult Massive bleeding Clots Gastric varices Portal encephalopathy  60% of cirrhotic pateints bleed form varices

25 M-W SYNDROM  Diagnostic possible ONLY WITH EMERGENCY ENDOSCOPY Lesions are short lived – Hypovolemic shoch is unlikely but not impossible – Short hospital stay – Very small risk of rebleeding

26 Hiatus hernia and reflux  Stigmata of recent bleeding  HH is very frequent

27 TUMORS  Overt GI bleeding is rare, frequently occult bleeding

28 Gastric sources of bleeding  Hemorrhagic gastritis  Gastric ulcer  Benign tumors  Malignant tumors

29 Hemorrhagic gastritis  DG: morphologic criteria  Endoscopic aspect is not diagnostic  Barium meal: useless and loss of money

30 Gastric ulcer  Diagnostic can be difficult  EDS: stigmata of recent bleeding  Risk of rebleeding evaluation

31 Benign tumors  Very unlikely, round circumscribed tumors with central ulcerations

32 Malignant tumors  Ex. endoscopic è Locally advanced tumor è Endoscopic hemostasis  US scan  MTS + lymphnodes

33 Upper GI bleeding with duodenal origin  Very frequent  Empiric treatment of upper GI bleeding  It is much to easy to say that a bleeding originates from a duodenal ulcer without endoscopy

34 Erosive gastritis  Term misused for many unknown situations responsible for bleeding  Superficial ulcerations usually described as superficial ulcer – easier to comprehend  HP infection

35 Bleeding peptic duodenal ulcer  Relatively frequent although potent medication is on the market  53% previous diagnostic of ulcer  17% iterative: More serious, high risk of rebleeding 25% no previous cause!!! Known diagnostic-treat that

36 Rebleeding risk

37 INTESTINAL OBSTRUCTION SYNDROME, MANY DISEASES

38 Small bowell obstruction

39 Essentials of diagnostic  Complete high obstruction – Vomiting – Abdominal discomfort – Rx changes  Low obstruction – Colicky pain – Vomiting – Abdominal distension – No intestinal transit – Hyperperistaltic movements – A/F levels

40 2 major forms of obstruction  Simple – Mechanical – Paralitical  Strangulation – Vascular component

41 Causes  Postoperative adhesions – most frequent  All hernias  Tumors (intraluminal, parietal sor extraintestinal)  Invagination  Volvulus  Foreign bodies  Billiary ileus  Inflammatory bowel disease  Stenosis  Hematoma  Etc

42 Symptoms  Colicky abdominal pain (no in very high small bowell obstruction) – Crescendo-descrescendo – Seconds - minutes – No pain between  Vomiting – Dominant symptom – Intervals depending on localization of obstruction – More distal - fecaloid

43 Symptoms  No transit for feaces or gas per anum – Feaces can be present in large bowel. Initial normal defecation  General signs may be absent or minimal – Dehydration – No fever  Abdomen: – Abdominal distension (not in high obstruction) – Hyperperistaltic waves can be seen on the abdomen – Abdomen may be tender – NO signs of peritoneal iritation – Abnormal sounds – CHECK FOR HERNIA

44 Paraclinical  Lab: non-specific – Hemoconcentration (increased WBC, hyperglicemia) – Electrolytic imbalance – High level serum amilase  Plain abdominal X-Ray – A/F levels and their position and form – Hydrosoluble contrast media

45 Particularities of strangulation  Shock develops very early  Pain is less colicky and becomes permanent  Fever  Vomiting + blood strikes  Abdominal guarding

46 Particularities of strangulation  High WBC  Rx: – Loss of normal mucosal lining – Air in portal veins or in intestinal wall – F/A levels outside intestinal lumen: abscess or pneumoperitoneum

47 LARGE BOWEL OBSTRUCTION

48 Essentials of diagnostic  Constipation or no feaces or flatus per anum  Meteorism +/- guarding  Abdominal pain  Nausea and vomiting – late  Important Rx findings

49 Frequent causes  Colonic malignant tumor  Volvulus  Diverticulosis - infected  IBD  Benign tumors  Fecal impactation  Lesions outside digestive tract

50 Symptoms  Dependent on the cometepence of ileo- cecal valve – Valvular lesion – similar with ileal obstruction – Competent valve – no vomiting – Incompetent valve - vomiting  Closed loop syndrome – Risk of cecal perforation

51 Symptoms  Progressive onset (mechanical obstruction)  Dull pain mainly in hypogastrium – Fixed colonic lesion may produce localized pain – Continuous pain - ischemia  Borborism associated with colicky pain  No feaces no flatus  Vomiting: changing character

52 Clinica examination  Meteorism and timpanism  Peristaltic waves on abdominal wall  Specific sounds - obstruction  Peritoneal irritation symptoms  Rectal – Bloos – Tumor – Invagination pseudotumor

53 Radiology  Colonic distention with gas  F/A levels (colonic)  Mixed A/F level signs if the ileo-cecal valve is incompetent  Barium enema (or water-soluble solution) – Level of obstruction – Ethiology – Devolvulation

54 Differential diagnostic  Low/high obstruction  Ileus (paralitic)  Pseudo-obstruction

55 Signs in acute pancreatitis Abdominal drama

56 Essentials of diagnostic  ABDOMINAL PAIN – Sudden onset – Dull pain irradiating transverse and to the back  Vomiting, Sweating, Fever  Distended abdomen  High WBC, amilazemia, amilazuria, lipazemia  PMH: alcohol, billiary calculus

57 General data  Severe inflammatory disease  Abnormal activation of pancreatic enzymes  Causes: – Alcohol, billiary calculus – Hypercalcemia, hyperlipidemie, trauma, reaction to medicines, vasculitis, infections  Inflamation: edema – hemorrhagic, necrotic severe form

58 Symptoms PAIN  Epigastric, severe, continuous, relieved in genu-pectoral position ;  IRRADIATION: TRANSVERSE  Nauseam vomiting: CHARACTERISTIC – impossibility to eat or drink  PMH: alcohol or billiary colicky

59 Abdominal examination  Very few elements  Diffuse sensibility in upper half of the abdomen  Ussually no guarding and no signs of peritoneal irritation  Paralitic Ileus – Abdominal distension – No bowel sounds – No flatus per anum  Abdominal pseudotumor in epigastrium and left upper quadran

60 General status  High fever>38  Septic state (tachycardia, hypotension, septic shock, palor, could periphery)  Jaundice (either compression, obstruction or secondary liver failure)  Renal failure

61 Lab  WBC  Hyperglicemia  High billirubin  High alkaline fosfataze  Hypocalcemia (loss of albumin through extraasation) ~ severity  Amilaze si lipaze serum + pleural and peritoneal effusion

62 Imagistic  Plain abdominal X-Ray = MUST – Differential dg. acute abdomen – Sentinel looop – left upper quadrant – Left pleural effusion + atelectasis – Incomplete F/A levels – Billiary stones – Fluid in the abdominal cavity

63 Imagistic  US – Standard procedure in screening – PROBLEM: air content – Pancreas: dimensions, edema, liquid collection pseudocysts – Free fluid in the abdomen and pleura – Guided aspiration for diagnostic

64 Imagistic  CT scan + contrast – Best for diagnostic and follow up – Information on pancreatic structure and fluid collections – Pancreatic tissue viability – Evaluation of peripancreatic collections – Free air in collections!!!!

65 Imagistic  MRI – No major advantages – Superior for the description of billiary duct – Not specifically indicated in acute pancreatitis

66 Differential diagnostic  Anything in acute abdomen  Myocardial infarction  After ERCP  Urlian virus infection  Intestinal obstruction  Aortic dissection  Mesenteric obstruction

67 Differential diagnostic SIGNIFICANCE  NO LAPAROTOMY NO LAPAROSCOPY IF DIAGNOSTIC – Sure – No billiary obstruction (except compression) – No suspicion of infection


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