andrew young march 22, 2012. diagnosis: bleeding duodenal ulcer procedures: pyloroplasty,...
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![Page 1: Andrew Young March 22, 2012. Diagnosis: Bleeding duodenal ulcer Procedures: Pyloroplasty, Truncal Vagotomy, G/J tube Transverse colectomy, Abthera](https://reader035.vdocuments.us/reader035/viewer/2022062217/56649f165503460f94c2c777/html5/thumbnails/1.jpg)
Andrew YoungMarch 22, 2012
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Diagnosis: Bleeding duodenal ulcer
Procedures: Pyloroplasty, Truncal Vagotomy, G/J tube Transverse colectomy, Abthera
placementComplication:
Death
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64yo woman with chronic back pain and large opiod requirement found down by EMS.
Resuscitated and transferred to MRICU from OSH Acute renal failure Unspecified liver disease (NAFLD?) Respiratory failure
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Past Medical History Chronic kidney
disease Hypertension Diabetes Spinal stenosis Anemia Chronic back pain Morbid obesity
Past Surgical History Cholecystectomy
(open) Hysterectomy Tubal ligation
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STICU Consult – 11:30 pm bleeding duodenal ulcer on EGD earlier that
day. Received 6 units of PRBC and still hypotensive
Intubated and sedated Pale and diaphoretic Vitals: 36.9 141 116/63 Ventilator 75%
Levophed at 150; Vasopressin at 0.04 Abd: obese, soft, NG with clear output
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Procedure: Pyloroplasty Truncal vagotomy G/J tube
Findings: 2 duodenal ulcers
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2am: Hgb 7.2 (from 8.1 day prior) 4am: confused, nausea, & coffee ground
emesis 8am:
Hgb 5.1 INR 1.6 1L NS, Levophed begun, 2 units PRBC, 2 FFP
10am: intubated for airway control 11am:
EGD two duodenal ulcers at bulb, one with clot Bronchoscopy: thin secretions
2pm: extubated
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6pm: unresponsive; hypotensive; Levophed at 65mcg Intubated
7pm: aline; Levophed at 90mcg; 1L NS 8pm: 1L NS 9pm:
CT abd/pelvis Levophed at 140mcg; Vasopressin begun; 1L NS
11pm: 3 units PRBC; Surgery consulted.
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Procedure: Pyloroplasty Truncal vagotomy G/J tube
Findings: 2 duodenal ulcers
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6am: 2 units of PRBC, 2 FFP, 1 Plt, 1 cryo 10am:
4 units PRBC, 5 FFP To OR for rexploration▪ Bleeding omental vessel ligated▪ Transverse colon ischemic - resected▪ 1.6L of clot evacuated; abdomen packed▪ Temporary abdominal closure device placed
Family meeting post op – care withdrawn.
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PyloroplastyTruncal Vagotomy
Other options: Pylorus sparing
duodenotomy HSV
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Judgement Offer operative intervention at all?▪ CKD, Liver disease, pulmonary disease▪ DM & Age
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Retrospective review: Demark1998 to 2002: 7k patientsBleeding ulcers: 30 day mortalityMortality (P = 0.003):
DM: 16% Without: 10%
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Judgement Offer operative intervention at all? Better resuscitation prior to going to OR
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“…the most frequently overlooked aspect of the initial management of the patient with upper GI bleeding…is the need to immediately attempt to establish hemodynamic stability and adequately resuscitate the patient.”
-Bruce Schirmer,Charlottesville, VA Mastery of Surgery, 5th Ed. 2007
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Judgement Offer operative intervention at all? Better resuscitation prior to going to OR
Technique 1.6L of blood in abdomen with “bleeding
vessel”
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Patients and families must be counseled on risk given comorbidities.
Bleeding ulcer: Resuscitate adequately EGD for first bleed Surgery for second bleed ~ 10%