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Surgical management of Acute GI Bleeding. Dr. F. Anaraki Colorectal surgeon Professor Assistant Ayatollah Taleghani Hospital. ACUTE GASTROINTESTINAL HEMORRHAGE. GI hemorrhage accounts for I% to 2% of acute admissions.
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Surgical management of Acute GI Bleeding Dr. F. Anaraki Colorectal surgeon Professor Assistant Ayatollah Taleghani Hospital
ACUTE GASTROINTESTINALHEMORRHAGE • GI hemorrhage accounts for I% to 2% of acute admissions. • Management of these patients is frequently multidisciplinary, involving emergency medicine, gastroenterology, intensive care, surgery, and interventional radiology. • Ultimately, 5% to lO% of patients hospitalized for bleeding require an operation intervention. • Mortality remains more than 5% which is related to the aging of the population, with an increase in comorbidity.
Upper GI hemorrhage from proximal to the ligament of Treirz accounts for more than 80% of cases of acute bleeding. Peptic ulcer disease and variceal hemorrhage arc the most common causes. • Most lower GI bleeding is from the colon, with diverticula and angiodysplasias accounting for most cases. • Obscure GI bleeding refers to GI bleeding for which no source has been identified by routine endoscopic studies (EGD and colonoscopy). Small-intestinal angiodysplasias account for approximately 75% of cases in adults. • Occult GI bleeding occurs in the absence of overt bleeding and is identified on laboratory tests (e.g., iron-deficiency anemia) or examination of the stool (e.g., positive guaiac test).
Risk Factors for Morbidity and Mortality inAcute Gastrointestinal Hemorrhage
Severity of the hemorrhage • Hemorrhagic shock: Obtundation, agitation, and hypotension (systolic blood pressure <90 mm Hg in the supine position), associated with cool clammy extremities = loss of more than 40% of the patients' blood volume. • Resting heart rate over 100 beats/min, with a decreased pulse pressure, implies a 20% to 40% volume loss. • Orthostatic hypotension = At least a 20% blood loss
ACUTE UPPER GI HEMORRHAGE Common causes of upper GI bleeding • Upper GI bleeding accounts for almost 80% of significant GI hemorrhage.
ACUTE UPPER GI HEMORRHAGE 20% to 35% of patients undergoing upper GI endoscopy will require a therapeutic endoscopic intervention, and 5% to 10% will eventually require surgery.
ACUTE UPPER GI HEMORRHAGE Indications for operation: Massive hemorrhage unresponsive to endoscopic control Transfusion requirement of more than four to six units of blood Lack of availability of a therapeutic endoscopist Recurrent hemorrhage after one or more attempts at endoscopic control Lack of availability of blood for transfusion Repeat hospitalization for bleeding ulcer Concurrent indications for surgery such as perforation or obstruction
ACUTE UPPER GI HEMORRHAGE • Earlyoperation should be considered for: • Massive bleeding from high-risk lesions (e.g., posterior duodenal ulcer with erosion of gastroduodenal artery, or lesser curvature gastric ulcer with erosion of left gastric artery or branch • Patients more than 60 years of age • Those presenting in shock • Those requiring more than four units of blood in 24 hours or eight units of blood in 48 hours • Ulcers >2 cm in diameter
Operation for Bleeding Peptic Ulcer • Oversewing of the ulcer usually without vagotomy . If the patient is stable, vagotomy may be considered if the surgeon is experienced. ( vagotomy + pyloroplasty) • Vagotomy and antrectomy
Acute Lower GI Bleeding Differential Diagnosis of Lower Gastrointestinal Hemorrhage • In more than 95% of patients with lower GI bleeding, the source of hemorrhage is the colon.
Colon and Rectum 95% Lower GIB
Colon and Rectal source of Lower GIB • Diverticulosis • Polyps and cancers • Colitis • Angioectasia • Coagulopathy • Hemorrhoid • Colorectal varices • Solitary Rectal Ulcer • Stercoral ulcer • Rupture of pancreatic pseudocyst into the colon
Small intestinal source of Lower GIB Acid-Related DisordersCeliac DiseaseCollagen-Vascular Diseases DrugsInfectionsInflammatory DiseasesIschemiaMetabolic RadiationToxins primary metastatic Meckel's Diverticulum Neoplasms Solitary ulcers
Ischemic colitis Angioectasia Colitis Diverticulosis Solitary Rectal Ulcer
Anorectal hemorrhage • Fissure • Hemorrhoid • Rectal Ulcer • Proctitis • Rectal varices
Evaluation of Lower GI bleeding • Once resuscitation has been initiated, the first step in the workup is to rule out anorectal bleeding with a digital rectal examination, anoscopy, and/or sigmoidoscopy. • With significant bleeding, it is also important to eliminate an upper GI source. An NG aspirate that contains bile and no blood effectively rules out upper tract bleeding in most patients. • When emergent surgery for life-threatening hemorrhage is being contemplated, preoperative or intraoperative EGO is usually appropriate. This is particularly relevant if blind subtotal colectomy for massive hemorrhage is being considered.
Emergent surgery for Lower GIB • Hemodynamically unstable patients • Patients who have had the source of bleeding localized but no therapeutic measures were performed or they failed • Patients who have required at least 6 units of packed red cells within 24 h
How to proceed? Open laparotomy through a midline incision The stomach, duodenum, small bowel, and colon are visually examined and palpated. If there is no identifiable bleeding source and localization was not successful, push intraoperative enteroscopy (IOE) can be considered. If no bleeding site is identified in the upper gastrointestinal tract or small bowel and the source is presumed to be colonic, then a total abdominal colectomy should be performed.
