1. Slide 1 of 21 Arie E Pelta, MD FACS FASCRS Kaplan Medical Center Department of General Surgery Colon & Rectal Surgery

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3. Slide 3 of 21 Age >60 yr Comorbid disease Renal failure Liver disease Respiratory insufficiency Cardiac disease Magnitude of the hemorrhage Systolic blood pressure <100 mm Hg on presentation Transfusion requirement Persistent or recurrent hemorrhage Onset of hemorrhage during hospitalization Need for surgery

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5. Slide 5 of 21 NONVARICEAL BLEEDING** PORTAL HYPERTENSIVE BLEEDING [†] [†] 30%-50% Peptic ulcer disease Gastroesophageal varices >90 15%-20% Mallory- Weiss tears Hypertensive portal gastropathy, <5 10%-15% Gastritis or duodenitis Isolated gastric varices, rare 5%-10% Esophagitis 5% Arteriovenous malformations 2% Tumors 5% Others

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10. Slide 10 of 21 Hemodynamic instability despite vigorous resuscitation (>6 U transfusion) Failure of endoscopic techniques to arrest hemorrhage Recurrent hemorrhage after initial stabilization (with up to two attempts at obtaining endoscopic hemostasis) Shock associated with recurrent hemorrhage Continued slow bleeding with a transfusion requirement >3 U/day

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15. Slide 15 of 21 COLONIC BLEEDING** SMALL BOWEL BLEEDING [†] [†] 30%-40% Diverticular disease Angiodysplasias 5%-10% IschemiaErosions, ulcers (e.g., from potassium, NSAIDs) 5%-15% Anorectal disease Crohn's disease 5%-10% NeoplasiaRadiation 3%-8% Infectious colitis Meckel's diverticulum 3%-7% Postpolypectomy Neoplasia 3%-4% Inflammatory bowel disease Aortoenteric fistula 3% Angiodysplasia 1%-3% Radiation colitis, proctitis 1%-5% Other 10%-25% Unknown

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21. Slide 21 of 21 A. Treatment is by balloon tamponade B. Bleeding often stops spontaneously C. It is caused by vomiting D. There is air in the mediastinum E. Diagnosis is made by physical examination

22. Slide 22 of 21 A. Treatment is by balloon tamponade arterial bleed worse with ballon cause perfororation B. Bleeding often stops spontaneously – 1929 Mallory and Weiss. Tx: gastrotomy and oversew; endoscopic inject epi/cautery C. It is caused by forceful vomiting against closed cardia D. There is air in the mediastinum E. Diagnosis is made by endoscopic examination

23. Slide 23 of 21 A. It is a more common common complication of DU than is perforation B. Endoscopic treatment before operation decreases mortality C. Endoscopic treatment decreases the need for operation D. Operative management is indicated only if endoscopic treatment fails E. Operative management should not include an acid- reducing procedure

24. Slide 24 of 21 A. It is a more common common complication of DU than is perforation – melena/hematemesis; eroded GDU B. Endoscopic treatment before operation decreases mortality C. Endoscopic treatment decreases the need for operation D. Operative management is indicated only if endoscopic treatment fails – active arterial spurting/visible vessel predict recurrent bleed E. Operative management should not include an acid- reducing procedure – suture ligate GDA vessels. Truncal vagotomy + pyloroplasty; parietal cell vagotomy + antrectomy

25. Slide 25 of 21 A. Prophylactic treatments with H2 blockers and anatacids are equally effective B.The incidence of such bleeding has been decreasing C. The site of hemorrhage is most often in the antrum D. There is minimal recurrent bleeding after treatment by oversewing of bleeding sites, vagotomy, and pyloroplasty E. Effective surgical treatment necessitates total gastrectomy

26. Slide 26 of 21 A. Prophylactic treatments with H2 blockers and anatacids are equally effective antacids best titrated to gastric pH; sucralfate works in acid environment B.The incidence of such bleeding has been decreasing C. The site of hemorrhage is most often in the antrum. - proximal fundus D. There is minimal recurrent bleeding after treatment by oversewing of bleeding sites, vagotomy, and pyloroplasty – superficial bleeding E. Effective surgical treatment necessitates total gastrectomy – only IF not controlled by vagotomy and pyloroplasty

27. Slide 27 of 21 A. It is a complication of GE reflux B. It involves esophageal rupture near the GE junction C. Profuse hemorrhage is the most common manifestation D. Bleeding can generally be managed medically E. Vagotomy is indicated for patients requiring surgical treatment

28. Slide 28 of 21 A. It is a complication of GE reflux retching B. It involves tear mucosa submucosa GE jct esophageal rupture near the GE junction. Tear gastric side lesser curve C. Profuse hemorrhage is 10% the most common manifestation D. Bleeding can generally be managed medically E. Vagotomy is indicated for patients requiring surgical treatment – oversew site of tear no acid reducing operation

29. Slide 29 of 21 A. They are found in various anatomic forms and clinical presentations in 50% of the population B. They are true diverticula C. All can be visualized on technetium 99m pertechnetate ( 99m Tc) scans D. Most complications occur in the elderly E. Diverticulitis is the most common complication

30. Slide 30 of 21 A. They are found in various anatomic forms and clinical presentations in 50% 2% of the population B. They are true diverticula – antimesenteric border 50cm from IC valve, band to umbilicus C. Some All can be visualized on technetium 99m pertechnetate ( 99m Tc) scans – ectopic gastric mucosa peptic ulcer and bleed D. Most complications occur in the elderly pediatrics E. Diverticulitis bleeding, intussusception, obstruction are is the most common complication – diverticulitis is the least complication. Tx: diverticulectomy for diverticulitis; SBR for bleeding. NO prophylactic diverticulectomy for incidental finding unless gastric mucosa or narrow neck

31. Slide 31 of 21 A. It is a simple, complication free, outpatient procedure that allows examination of the entire length of small intestine B. Capsule endoscopy is not well tolerated by pts since the capsule is attached to a thin wire externalized through the nose to power the device and transmit images C. Capsule endoscopy of the SB may be completed in 1 day D. The capsule endoscope is reusable E. Endoscopic images are viewed using existing endoscopic imaging systems

32. Slide 32 of 21 A. It is a simple, complication free, outpatient procedure that allows examination of the entire length of small intestine – 1.cm in diameter can cause SBO B. Capsule endoscopy is not well tolerated by pts since the capsule is attached to a thin wire externalized through the nose to power the device and transmit images C. Capsule endoscopy of the SB may be completed in 1 day - reach colon in 7hrs D. The capsule endoscope is not reusable E. Endoscopic images are viewed using existing endoscopic imaging systems

33. Slide 33 of 21 A. Capsule endoscopy has replaced push enteroscopy in the evaluation of the SB B. Capsule endoscopy is available only in specialized centers participating in clinical trials C. Intraoperative enteroscopy is a simple, safe technique that eliminates the need for the less sensitive technique of capsule endoscopy D. Push enteroscopy is more sensitive and specific than capsule endoscopy in the area that can be examined by push enteroscopy

34. Slide 34 of 21 A. Capsule endoscopy has replaced push enteroscopy in the evaluation of the SB – enteroscopy only examine 50cm from prox or distal direction miss central SB B. Capsule endoscopy is available only in specialized centers participating in clinical trials C. Intraoperative enteroscopy is a simple, safe technique that eliminates the need for the less sensitive technique of capsule endoscopy - laparotomy D. Push enteroscopy is more sensitive and specific than capsule endoscopy in the area that can be examined by push enteroscopy

35. Slide 35 of 21 A. Cancer B. UC C. Diverticulosis D. Diverticulitis E. Angiodysplasia

36. Slide 36 of 21 A. Cancer – occult bleed B. UC – mild bleeding C. **Diverticulosis ** – ruptured vasa recta D. Diverticulitis – mild bleeding E. Angiodysplasia – equal frequency with diverticulosis. Aging, intramural muscular hypertrophy obstructs the submucosal veins cause dilatation and bleed

37. Slide 37 of 21 A. Angiography B. Nuclear medicine RBC scan C. Rigid proctoscopy D. Colonoscopy E. BE

38. Slide 38 of 21 A. Angiography – 1 ml/min. #1SMA most bleeds R colon, #2 IMA, #3 celiac. Embolize, 25% rebleed, 5% ischemia/infarction. Vasopressin intra-arterial, cause arrythmia; when stop 30% rebleed. B. Nuclear medicine RBC scan – sulfur colloid cleared rapid. Technetium detect 0.1 ml/min can repeat scan C. Rigid proctoscopy – anorectal source, UC mucosa D. Colonoscopy – not use when bleed briskly. No bowel prep E. BE – barium will obscure angio; not show bleeding

39. Slide 39 of 21 A. 50% cases bleed Right colon B. Bleeding is arterial and severe C. After 1 st episode, rate of recurrent bleed is 25% D. Extravasation of dye during angio can be seen in MOST cases E. Total colectomy is the procedure of choice a. Diverticulosis b. Angiodysplasia c. Both d. Neither

40. Slide 40 of 21 A. 50% cases bleed Right colon – (c) 80% of tics in sigmoid but R side bleeds more B. Bleeding is arterial and severe – (a). Angiodyslasia is Venous. C. After 1 st episode, rate of recurrent bleed is 25% - (c) rebleed after 2 nd episode is 50%. Angiodysplasia 85% rebleed D. Extravasation of dye during angio can be seen in MOST cases – (a) angiodysplasia extravasate only 10%. Dense slowly emptying vein, vascular tuft, early filling vein E. Total colectomy is the procedure of choice – (d) prefer limited resection a. Diverticulosis b. Angiodysplasia c. Both d. Neither