1. Alcoholic, Hit by Motorcycle, with Abdominal Pain and Hematemesis Peter R. Peacock, Jr. M.D. SUNY-Downstate Kings County Hospital

2. Alcoholic  37 years old  100-200 grams / day EtOH

3. With Abdominal Pain  For several weeks  Upper abdomen  Worse in ED  Diffusely tender abdomen  No peritoneal signs

4. Struck by Motorcycle Complaining of neck, back, abdominal pain

5. With Massive Frank Hematemesis  75 minutes after arrival  Bright red  > 1000 ml  Guaiac-positive dark brown stool

6. And Several Laboratory Abnormalities  Anemia  Coagulopathy  Hepatocellular injury  Hypoproteinemia

7. Case Overview Alcoholic With abdominal pain Struck by motorcycle With frank hematemesis And several lab abnormalities

8. Lucas CE, Ledgerwood AM in Feliciano DV Trauma Physiological Effects of Chronic Ethanol Abuse  Electrolyte abnormalities  Nutritional deficiencies  Cirrhosis  Cognitive disability

9. Morris, JA, JAMA. 263(14);1942 Impact of Chronic Medical Conditions on Trauma Mortality  Cirrhosis4.6  Congenital coagulopathy3.2  COPD1.8  Ischemic heart disease1.8  Diabetes1.2  Hypertension, obesity, substance dependence, and several CNS diseases showed no difference

10. Case Overview Alcoholic With abdominal pain Struck by motorcycle With frank hematemesis And several lab abnormalities

16. Likely causes in Our Patient  Gastritis  Peptic or Duodenal ulcer disease  Pancreatitis  Pancreatic pseudocyst  Hepatitis  Hepatic distention  Splenomegaly

17. Case Overview Alcoholic With abdominal pain Struck by motorcycle With frank hematemesis And several lab abnormalities

18. Struck by Motorcycle Complaining of neck, back, abdominal pain  ???  Lower extremity  Thoracoabdominal injury  Secondary impact from fall  Monteggia

19. Injury Mechanism Blunt abdominal trauma  Solid organ injury  Compression, rupture of filled viscera  Incomplete intralumenal tears  Crush of viscera  Shearing of vascular pedicles

21. Case Overview Alcoholic With abdominal pain Struck by motorcycle With frank hematemesis And several lab abnormalities

23. Diagnoses that can be Excluded  Arterioenteric fistula  “Pseudohematemesis”  Perforation

26. Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 6th ed

28. X X X   ?

29. Possible Non-Traumatic Diagnoses  Bleeding varices  Mallory-Weiss tear  Peptic ulcer disease  Hemosuccus pancreaticus

30. What is Hemosuccus Pancreaticus?  aka Pancreatic Pseudoaneurysm  Pancreatic pseudocyst erodes into peripancreatic artery  Causes bleeding  Via pancreatic duct or cyst rupture  Slow and intermittent or acute and massive  90% mortality without treatment

31. Traumatic Etiologies of Hematemesis  Esophageal injury  Gastric injury  Duodenal injury  Pancreatic or biliary injury  Pseudohematemesis  “Two-hit” etiologies

32. Blunt Esophageal Injury  Rare: ~0.1% in fatal automobile accidents  Hematemesis is part of syndrome  Also expect rigid abdomen, subcutaneous and mediastinal air, pleural effusion

33. Moylan, Feliciano Blunt Gastric Injury  Uncommon  10/539 positive laparotomies  Preseley Regional, blunt trauma  UGIB is typical presentation  Exsanguination possible  Range of injuries  Mucosal laceration to rupture to vascular pedicle injury  Associated IAIs

34. Blunt Duodenal Injury  Relatively common injury  69/539 positive laparotomies  Preseley Regional, blunt trauma  Intramural hematoma most common  With rupture  Abdominal and back pain  50% with retroperitoneal air on plain films

35. Pancreatic or Biliary Injury Theoretically UGIB via ampulla of Vater  Pancreas  Uncommon  Hematemesis?  Gall bladder injury  Rare  Delayed presentation of bleeding

36. Two-Hit Etiologies  Assumes a visceral injury  Could hemoperitoneum present as hematemesis?

37. Two-Hit Etiologies  Spleen and Liver injury  Most common causes of hemoperitoneum  Good mechanism  Our patient at higher risk  Others: vascular injury, renal injury, small bowel injury

38. Some Common Sense No bleeding starts and stops like a faucet  A liter of blood  It accumulated  Where but the stomach?  Stomach with hole leaks  No accumulation

39. Massive Hematemesis Short List  Blunt gastric injury  Bleeding varices  Mallory-Weiss tear  Peptic ulcer disease  Hemosuccus pancreaticus

40. Case Overview Alcoholic With abdominal pain Struck by motorcycle With frank hematemesis And several lab abnormalities

41. DDx: Laboratories  Complications of alcoholism: acute alcoholic hepatitis, malnutrition  +/- Cirrhosis  Effects of large-volume resuscitation  Other liver pathologies  Nephrotic syndrome

43. Phillips TF, J Trauma 27:903 Could Resuscitation Cause This? Risk factors for coagulopathy in trauma include the following  Shock  Dilution  Packed RBC and crystalloid  Dilution of clotting factors (if no FFP)  Dilutional thrombocytopenia  Acidosis  Hypothermia  Via platelet prostaglandin metabolism

44. Does our patient have cirrhosis?  History  His ethanol consumption is sufficient  10% of alcoholics will develop cirrhosis  Physical  Laboratory

45. Does our patient have cirrhosis? Physical Exam  Hepatomegaly most common finding in alcoholic liver disease  What else is there?

51. Hamberg KJ, J Clin Epidemiol 49:1295

52. Czaja AJ, Mayo Clin Proc 49:1295 Does our patient have cirrhosis? Laboratory Biochemical assays less predictive than clinical exam  Hypoalbuminemia  Relatively sensitive (69%)  Non-specific  Thrombocytopenia  Prothrombin  Relatively good markers  Our patient?

53. Does our patient have Cirrhosis?  History  ~13% pre-test probability  The physical exam  None of the diagnostic findings  Labs  Very weakly suggestive

54. Putting it all together  Start with hematemesis differential  Estimate probability of each  See which may have been precipitated by BAT  See which diagnoses could explain preceding abdominal pain

55. Massive Hematemesis Short List  Mallory-Weiss tear  Variceal hemorrhage  Peptic ulcer disease  Blunt gastric injury  Pancreatic pseudoaneurysm

56. Feldman, Sleiseger & Fortran's GI and Liver Disease, 6th Ed What’s the Prevalence of a Varix that would Bleed?  > 50% of patients with cirrhosis have varices  ~30% of those bleed within 2 years  0.05 x 0.5 x 0.3 = 0.0075 so, 7.5/1000 alcoholics will develop varices

57. What’s the likelihood of Peptic Ulcer or Mallory-Weiss?

58. Feldman, Sleiseger & Fortran's GI and Liver Disease, 6th Ed What’s the Prevalence of Pseudoaneurysm?  5-15% of alcoholics  chronic pancreatitis  25% chronic pancreatitis  pseudocysts  10% of those  pancreatic pseudoaneurysm  0.15 x 0.25 x 0.10 = 0.00375 so 4/1000 alcoholics will develop pseudoaneurysm

59. What’s the Prevalence of Blunt Gastric Injury?  ~ One in 15 BAT get laparotomy  10/539 of these have BGI  1.0 / 15 x 10 / 539 = 0.0012 1/1000 victims of BAT suffer BGI

60. Putting it all together  Start with hematemesis differential  Estimate probability of each  See which may have been precipitated by BAT  See which diagnoses could explain preceding abdominal pain

61. Hematemesis after Blunt Abdominal Trauma  Blunt gastric injury  Pancreatic pseudoaneurysm  Cyst rupture  Mallory-Weiss tear  Valsalva  Variceal hemorrhage  Hepatic venous pressure gradient

62. Pre-Injury Abdominal Pain  Red herring  Not red herring  Peptic ulcer disease  Pancreatic pseudoaneurysm

63. Diagnostic Approach Do we have the CT result? Dx / Tx of choice – Pseudoaneurysm – Angio – Varix, BGI, M-W tear – EGD – Other IAI – Surgery / Angio DPL – Assess significance of peritoneal fluid – R/O significant IAI EGD is a bedside test

64. My Final Diagnosis  Hemosuccus Pancreaticus  Variceal Bleeding  Blunt Gastric Injury  Mallory-Weiss tear