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 Clinical presentations
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 Paracentesis + lavaj
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. Syndrome: GROUP of diseases which may be unrelated
Upper GI bleeding
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 ulcer 24% Erosive gastritis 23% Gastric ulcer 21%
Esofageal varices 10%
Esofagitis 8%
Sdr. M-W 7%
Erosive duodenitis 6%
Tumors 3%
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? endoscopy “GOLD DIAGNOSTIC” 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 US abdominal Barium meal
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 US scan Locally advanced tumor
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 Plain abdominal X-Ray
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 10.000-30.000 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