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Stomach
Presley Regional Trauma Center Department of Surgery
University of Tennessee Health Science Center Memphis, Tennessee
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Gastrointestinal Bleeding
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• Bleeding that occurs proximal to the ligament of Treitz
• Significant source of mortality for both emergency admissions (11%) and inpatients (33%)
UGIB
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• Esophagus Varices MW tears
• Stomach Gastritis Varices Ulcers CA
• Duodenum Ulcers
Sources
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• Severe bleeding
• Hematemesis
• Hematochezia
• Hypotension
• Gradual bleeding with melena
• Occult bleeding
Presentation
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• Based on the perceived rate of bleeding and degree of hemodynamic stability
• ABCs
• CBC, chemistries, PT, PTT
• Type and cross
• Every effort should be made to resuscitate and stabilize the patient
Evaluation
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Clinical Evaluation
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• Focus on known causes of GIB
• Meds that interfere with coagulation or alter hemodynamics
• Nature and duration of the bleeding
History
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• Seldom useful in determining bleeding site
• Postural VS can estimate IV volume status
• bp drop > 10 mmHg or HR increase > 10 beats/min = >15% of total circulating blood volume has been lost
• Marked tachycardia with tachypnea in association with hypotension and depressed mental status = >30%
Physical
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• 3 results
- Gross blood or coffee grounds
- Bile
- Clear
Gastric Lavage
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UGIB Investigative Tests
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• Almost always reveals the source of UGIB
• Both diagnostic and therapeutic
• Therapeutic maneuvers – Injection
– Thermal coagulation – Mechanical occlusion (clips, banding)
EGD
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• Tagged RBC scan May confirm the presence of active bleeding Fairly non-specific with respect to determining
the anatomic location
• Angiography May demonstrate that a lesion is present
Cannot reliably identify a bleeding site unless the bleeding is brisk (> 1ml/min)
May reveal cause even if bleeding has stopped
Imaging
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• CT
• Enteroscopy
• Capsule endoscopy
Alternatives
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• Bleeding persists despite negative endoscopy, angio and RBC scan
• Diagnostic challenge
• Provocative angio
Obscure Bleeding
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• Spontaneous hyperdensity of peribowel fat
• Contrast enhancement of bowel wall
• Extravasation
• Thickening of bowel wall
• Polyps or tumors
• Vascular dilatation
CT
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• Push endoscopy
• Proximal 150 cm of small bowel
• Double balloon enteroscopy
Enteroscopy
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Specific Sources of UGIB
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• Decision making Active bleeding?
Attempt endoscopic control
Hemodynamic stability
Ongoing transfusion requirements
Duodenal Ulcer
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• Surgical intervention Substantial bleeding Not controlled endoscopically
Hemodynamically unstable Visible vessel Active bleeding
Adherent clot Giant ulcer
Duodenal Ulcer
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• Bleeding controlled endoscopically PPI
H. pylori treatment
• Bleeding recurs Repeat attempt at endoscopic cnotrol
OR
Outcomes
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• Classified by location and role (if any) that gastric acid hypersecretion plays
• Type I = lesser curve, not associated with acid secretion
• Type II = lesser curve, occurring in synchrony with duodenal ulcers, associated with high acid secretion
Gastric Ulcer
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• Type III = prepyloric, associated with high acid secretion
• Type IV = cardia, near GE jnc, not associated with acid secretion
• Type V = diffuse, associated with use of medications
Gastric Ulcer
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• Bleeding less common than with duodenal ulcers
• Initial management is similar
• Those that require operative intervention should be treated with resection
Gastric Ulcer
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• Type I = wedge resection
• Type II and III = V & A
• Type IV = Csendes procedure
Operative Management
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Post-gastrectomy Syndromes
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• A number of syndromes have been described that are associated with distressing symptoms after gastric operations performed for peptic ulcer or gastric neoplasm
• The occurrence of severe postoperative symptoms is fortunately low, perhaps 1% to 3% of cases, but the disturbances can be disabling
Overview
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• Denotes a clinical syndrome with both gastrointestinal and vasomotor symptoms
• The precise cause is not known but is believed to relate to the unmetered entry of ingested food into the proximal small bowel after vagotomy and either resection or division of the pyloric sphincter
Dumping
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• Early – symptoms occur immediately after a meal and include nausea, epigastric discomfort, borborygmi, palpitations, and, in extreme cases, dizziness or syncope
• Late – symptoms follow a meal by 1 to 3 hours and can include reactive hypoglycemia in addition to the above symptoms
Types
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• Although a relatively large number of patients experience mild dumping symptoms in the early post-op period, minor dietary alterations and the passage of time bring improvement in all but approximately 1%
• Octreotide has been reported to improve dumping symptoms when administered subcutaneously before a meal
Octreotide
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• The beneficial effects on the vasomotor symptoms of dumping are postulated to be due to pressor effects on splanchnic vessels
• Inhibits the release of vasoactive peptides from the gut, decrease peak plasma insulin levels, and slow intestinal transit
Octreotide
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• Should be reserved for patients who demonstrate the clinical triad of postprandial epigastric pain often associated with nausea and vomiting, evidence of reflux of bile into the stomach, and histologic evidence of gastritis
• One or more of these findings occur transiently in 10-20% of patients after gastric resection, but persist in only 1-2%
Alkaline Reflux Gastritis
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• Recurrent ulceration, biliary and pancreatic disease, afferent loop obstruction, and esophagitis
• Gastric acid analysis shows basal hypochlorhydria with little increase with pentagastrin stimulation
• Serum gastrin levels should be determined to r/o ZE syndrome and retained antrum
• Endoscopic examination is essential to exclude recurrent ulcer
Post-op Epigastric Pain
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• The only proven treatment is operative diversion of intestinal contents from contact with the gastric mucosa
• The most common procedure = Roux-en-Y gastrojejunostomy with an intestinal limb of 50 to 60 cm constructed to prevent reflux of intestinal contents
Management
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• This procedure is effective in eliminating bilious vomiting (nearly 100%), but recurrent or persistent pain is reported in up to 30% of patients, and up to 20% of patients are troubled with postoperative delayed gastric emptying
Management
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• Postsurgical gastroparesis is a syndrome characterized by gastric hypomotility in the absence of mechanical obstruction
• Incidence has been estimated at 2-3% after partial gastrectomy and vagotomy
• Appears to occur more commonly after operations for GOO and in diabetics
Gastroparesis
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• Symptoms include abdominal pain, postprandial nausea, vomiting, and weight loss months after gastric resection
• The diagnosis is one of exclusion, and careful evaluation with endoscopy and barium studies is required to exclude mechanical GOO
Gastroparesis
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• The pathogenic mechanism is related to loss of vagal innervation of the stomach, coupled with loss of antral pump function after antrectomy
• Treatment of consists of prokinetic agents or revisional gastric surgery
• Most recommend a 6-12-month trial of medical therapy prior to revisional surgery
Gastroparesis
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• Success rates of medical therapy have been disappointing, with response rates in the 20-30% range
• Surgical therapy is directed at eliminating the gastric reservoir with a near-completion gastrectomy and Roux-en-Y gastrojej
• In selected patient series, symptomatic success rates of 70-80% have been reported
Gastroparesis
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Other Sources of UGIB
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• Value of endoscopy in Dx and management cannot be overemphasized
• Bleeding can be nonvariceal in pts with known varices
• Banding or intravariceal sclerotherapy
• Balloon tamponade
• Somatostatin ± vasopressin
Esophageal Varices
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• Operative intervention – Uncontrolled hemorrhage – Persistent re-bleeding despite endoscopic
and medical therapy
• Determine if transplant candidate • Avoid operation
• Decompress portal venous system – TIPS
Esophageal Varices
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• Not a transplant candidate • Options Distal splenorenal shunt Portacaval or mesocaval shunt
Esophageal transecton Sugiura procedure
• Splenic vein thrombosis Splenectomy
Esophageal Varices
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• Linear tears at GE jnc secondary to emesis
• Usually self-limited • Injection • Clips • Banding • Coagulation • Oversewn
Mallory-Weiss Tears
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• Major trauma with shock, sepsis, respiratory failure, hemorrhage, or multiorgan injury
• Virtually always managed medically
- PPIs, H2 blockers
- H. pylori treatment if present
- Somatostatin
• Total or near total gastrectomy may be required
Stress Gastritis
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• Rupture of a 1 to 3 mm bleeding vessel through the gastric mucosa without surrounding ulceration
• Most commonly found high on lesser curve
• Can occur anywhere throughout GI tract
• Endoscopic therapy – 95% success
Dieulafoy Lesion
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• Epigastric and RUQ pain
• GIB
• Jaundice
• Angio – diagnostic and therapeutic
Hemobilia
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• Bleeding into pancreatic duct
• Erosion of a pancreatic pseudocyst into splenic artery
• Significant GIB coupled with abdominal pain, h/o EtOH abuse or pancreatitis should suggest Dx
• Angio – diagnostic and therapeutic
Hemosuccus Pancreaticus
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• May occur spontaneously
• Rupture of AA or perforation of duodenal lesion
• More often – arise after aortic surgery
• Herald bleed
• CT
Aortoenteric Fistula
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• Resuscitate patient
• Correct coagulopathy
• Localize bleeding source
• Cannot operate on bleeding alone
For Your Own Good