Intraperitoneal & retroperitoneal haemorrhage

1. Intraperitoneal & retroperitoneal haemorrhage

2. Complex ethiologyany 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: 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 VSTREATAMENT • 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. ANAMNESISpatient + 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 pateintsbleed 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 rebleedingevaluation

31. Benign tumors • Very unlikely, round circumscribed tumors with central ulcerations

32. Malignant tumors • Ex. endoscopic • 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. Complete high obstruction Vomiting Abdominal discomfort Rx changes Low obstruction Colicky pain Vomiting Abdominal distension No intestinal transit Hyperperistaltic movements A/F levels Essentials of diagnostic

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

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

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