General Surgery - Upper GI Bleeding Flashcards
What is upper GI bleeding?
Bleeding into the lumen of the proximal
GI tract, proximal to the ligament of
Treitz
What are the signs/symptoms?
Hematemesis, melena, syncope,
shock, fatigue, coffee-ground emesis,
hematochezia, epigastric discomfort,
epigastric tenderness, signs of
hypovolemia, guaiac-positive stools
Why is it possible to have hematochezia?
Blood is a cathartic and hematochezia
usually indicates a vigorous rate of
bleeding from the UGI source
Are stools melenic or
melanotic?
Melenic (melanotic is incorrect)
How much blood do you
need to have melena?
>50 cc of blood
What are the risk factors?
Alcohol, cigarettes, liver disease, burn/
trauma, aspirin/NSAIDs, vomiting,
sepsis, steroids, previous UGI bleeding,
history of peptic ulcer disease (PUD),
esophageal varices, portal hypertension,
splenic vein thrombosis, abdominal aortic
aneurysm repair (aortoenteric fistula),
burn injury, trauma
What is the most common
cause of significant UGI
bleeding?
PUD—duodenal and gastric ulcers (50%)
What is the common differential diagnosis of UGI bleeding?
- *1. Acute gastritis
2. Duodenal ulcer**
3. Esophageal varices
4. Gastric ulcer
5. Esophageal
6. Mallory-Weiss tear
What is the uncommon differential diagnosis of UGI bleeding?
Gastric cancer, hemobilia, duodenal
diverticula, gastric volvulus, Boerhaave’s
syndrome, aortoenteric fistula,
paraesophageal hiatal hernia, epistaxis,
NGT irritation, Dieulafoy’s ulcer,
angiodysplasia
Which diagnostic tests are
useful?
History, NGT aspirate, abdominal x-ray, endoscopy (EGD)
What is the diagnostic test of
choice with UGI bleeding?
EGD (>95% diagnosis rate)
What are the treatment options with the endoscope during an EGD?
Coagulation, injection of epinephrine
(for vasoconstriction), injection of
sclerosing agents (varices), variceal ligation
(banding)
Which lab tests should be
performed?
Chem-7, bilirubin, LFTs, CBC, type & cross, PT/PTT, amylase
Why is BUN elevated?
Because of absorption of blood by the GI
tract
What is the initial treatment?
-
IVFs (16 G or larger peripheral
IVS x 2), Foley catheter (monitor
fluid status) -
NGT suction (determine rate and
amount of blood) - Water lavage (use warm H2O—will
remove clots) -
EGD: endoscopy (determine etiology/
location of bleeding and possible
treatment—coagulate bleeders)
Why irrigate in an upper GI bleed?
To remove the blood clot so you can see
the mucosa
What test may help identify
the site of MASSIVE UGI
bleeding when EGD fails to
diagnose cause and blood
continues per NGT?
Selective mesenteric angiography
What are the indications for surgical intervention in UGI bleeding?
Refractory or recurrent bleeding and site
known, >3 u PRBCS to stabilize or
>6 u PRBCs overall
What percentage of patients
require surgery?
~10%
What percentage of patients
spontaneously stop bleeding?
~80% to 85%
What is the mortality of acute UGI bleeding?
Overall 10%, 60–80 years of age 15%,
older than 80 years of age 25%
What are the risk factors for death following UGI bleed?
Age older than 60 years
Shock
>5 units of PRBC transfusion
Concomitant health problems
What is Peptic Ulcer Disease (PUD)?
Gastric and duodenal ulcers
What is the incidence in the United States?
~10% of the population will suffer from
PUD during their lifetime!
What are the possible
consequences of PUD?
Pain, hemorrhage, perforation, obstruction
What percentage of patients
with PUD develops bleeding
from the ulcer?
~20%
Which bacteria are
associated with PUD?
Helicobacter pylori
What is the treatment?
Treat H. pylori with MOC or ACO
2-week antibiotic regimens:
MOC: Metronidazole, Omeprazole,
Clarithromycin (Think: MOCk)
or
ACO: Ampicillin, Clarithromycin,
Omeprazole
What is the name of the sign
with RLQ pain/peritonitis as
a result of succus collecting
from a perforated peptic
ulcer?
Valentino’s sign
In which age group are duodenal ulcers most common?
40–65 years of age (younger than
patients with gastric ulcer)
What is the ratio of male to
female patients?
Men > women (3:1)
What is the most common location?
Most are within 2 cm of the pylorus in
the duodenal bulb
What is the classic pain response to food intake?
Food classically relieves duodenal ulcer
pain (Think: Duodenum = Decreased
with food)
What is the cause?
Increased production of gastric acid
What syndrome must you
always think of with a
duodenal ulcer?
Zollinger-Ellison syndrome
What are the associated risk factors?
Male gender, smoking, aspirin and other
NSAIDs, uremia, Z-E syndrome,
H. pylori, trauma, burn injury
What are the symptoms?
Epigastric pain—burning or aching, usually
several hours after a meal (food, milk,
or antacids initially relieve pain)
Bleeding
Back pain
Nausea, vomiting, and anorexia
↓ appetite
What are the signs?
Tenderness in epigastric area (possibly),
guaiac-positive stool, melena,
hematochezia, hematemesis
What is the differential diagnosis?
Acute abdomen, pancreatitis, cholecystitis,
all causes of UGI bleeding, Z-E
syndrome, gastritis, MI, gastric ulcer,
reflux
How is the diagnosis made?
History, PE, EGD, UGI series
(if patient is not actively bleeding)
When is surgery indicated with a bleeding duodenal ulcer?
Most surgeons use: >6 u PRBC
transfusions, >3 u PRBCs needed to
stabilize, or significant rebleed
What EGD finding is associated with rebleeding?
Visible vessel in the ulcer crater, recent
clot, active oozing
What is the medical treatment?
PPIs (proton pump inhibitors) or H2
receptor antagonists—heal ulcers in
4 to 6 weeks in most cases
Treatment for H. pylori
When is surgery indicated?
The acronym “I HOP”:
Intractability
Hemorrhage (massive or relentless)
Obstruction (gastric outlet obstruction)
Perforation
How is a bleeding duodenal ulcer surgically corrected ?
Opening of the duodenum through the
pylorus
Oversewing of the bleeding vessel
What artery is involved with
bleeding duodenal ulcers?
Gastroduodenal artery
What are the common
surgical options for the
following conditions:
Duodenal perforation?
Graham patch (poor candidates, shock,
prolonged perforation)
Truncal vagotomy and pyloroplasty
incorporating ulcer
Graham patch and highly selective
vagotomy
Truncal vagotomy and antrectomy
(higher mortality rate, but lowest
recurrence rate)
Duodenal obstruction resulting from ulcer scarring (gastric outlet obstruction)?
Truncal vagotomy, antrectomy, and duodenal gastroduodenostomy (BI or BII) Truncal vagotomy and drainage procedure (gastrojejunostomy)
Duodenal ulcer intractability?
PGV (highly selective vagotomy)
Vagotomy and pyloroplasty
Vagotomy and antrectomy BI or BII
(especially if there is a coexistent
pyloric/prepyloric ulcer) but
associated with a higher mortality
Which ulcer operation has
the highest ulcer recurrence
rate and the lowest dumping
syndrome rate?
PGV (proximal gastric vagotomy)
Which ulcer operation has
the lowest ulcer recurrence
rate and the highest
dumping syndrome rate?
Vagotomy and antrectomy
Why must you perform a
drainage procedure
(pyloroplasty, antrectomy)
after a truncal vagotomy?
Pylorus will not open after a truncal vagotomy
Which duodenal ulcer operation has the lowest mortality rate?
PGV (1/200 mortality), truncal vagotomy
and pyloroplasty (1–2/200), vagotomy
and antrectomy (1%–2% mortality)
Thus, PGV is the operation of choice
for intractable duodenal ulcers with
the cost of increased risk of ulcer
recurrence
What is a “kissing” ulcer?
Two ulcers, each on opposite sides of the
lumen so that they can “kiss”
Why may a duodenal rupture be initially painless?
Fluid can be sterile, with a nonirritating
pH of 7.0 initially
Why may a perforated
duodenal ulcer present as
lower quadrant abdominal
pain?
Fluid from stomach/bile drains down paracolic gutters to lower quadrants and causes localized irritation
In which age group are gastric ulcers most common?
40–70 years old (older than the duodenal
ulcer population)
Rare in patients younger than 40 years
How does the incidence in
men compare with that of
women?
Men > women
Which is more common overall: gastric or duodenal ulcers?
Duodenal ulcers are more than twice as
common as gastric ulcers (Think:
Duodenal = Double rate)
What is the classic pain
response to food?
Food classically increases gastric ulcer pain
What is the cause?
Decreased cytoprotection or gastric
protection (i.e., decreased bicarbonate/
mucous production)
Is gastric acid production
high or low?
Gastric acid production is normal or low!
Which gastric ulcers are
associated with increased
gastric acid?
Prepyloric
Pyloric
Coexist with duodenal ulcers
What are the associated risk factors?
Smoking, alcohol, burns, trauma, CNS
tumor/trauma, NSAIDs, steroids, shock,
severe illness, male gender, advanced age
What are the symptoms?
Epigastric pain
+/- Vomiting, anorexia, and nausea
How is the diagnosis made?
History, PE, EGD with multiple biopsy
(looking for gastric cancer)
What is the most common
location?
~70% are on the lesser curvature; 5% are on the greater curvature
When and why should biopsy be performed?
With all gastric ulcers, to rule out gastric
cancer
If the ulcer does not heal in 6 weeks after
medical treatment, rebiopsy (always
biopsy in O.R. also) must be performed
What is the medical treatment?
Similar to that of duodenal ulcer—PPIs or
H2 blockers, Helicobacter pylori treatment
When do patients with gastric ulcers need to have an EGD?
- For diagnosis with biopsies
- 6 weeks postdiagnosis to confirm
healing and rule out gastric cancer!
What are the indications for
surgery?
The acronym “I CHOP”:
Intractability
Cancer (rule out)
Hemorrhage (massive or relentless)
Obstruction (gastric outlet obstruction)
Perforation
(Note: Surgery is indicated if gastric
cancer cannot be ruled out)
What is the common operation for hemorrhage, obstruction, and perforation?
Distal gastrectomy with excision of the ulcer **without** vagotomy unless there is duodenal disease (i.e., BI or BII)
What are the options for
concomitant duodenal and
gastric ulcers?
Resect (BI, BII) and truncal vagotomy
What is a common option
for surgical treatment of a
pyloric gastric ulcer?
Truncal vagotomy and antrectomy (i.e., BI or BII)
What is a common option for
a poor operative candidate
with a perforated gastric
ulcer?
Graham patch
What must be performed in
every operation for gastric
ulcers?
Biopsy looking for gastric cancer
# Define the following terms: Cushing’s ulcer
PUD/gastritis associated with neurologic
trauma or tumor (Think: Dr. Cushing =
NeuroSurgeon = CNS)
Curling’s ulcer
PUD/gastritis associated with major burn
injury (Think: curling iron burn)
Marginal ulcer
Ulcer at the margin of a GI anastomosis
Dieulafoy’s ulcer
Pinpoint gastric mucosal defect bleeding
from an underlying vascular malformation
What are the symptoms of a perforated peptic ulcer?
What causes pain in the
lower quadrants?
Passage of perforated fluid along colic gutters
What are the signs of a perforated peptic ulcer?
Decreased bowel sounds, tympanic
sound over the liver (air), peritoneal
signs, tender abdomen
What are the signs of
posterior duodenal erosion/
perforation?
Bleeding from gastroduodenal artery (and possibly acute pancreatitis)
What sign indicates anterior
duodenal perforation?
Free air (anterior perforation is more common than posterior)
What is the differential diagnosis?
Acute pancreatitis, acute cholecystitis,
perforated acute appendicitis, colonic
diverticulitis, MI, any perforated viscus
Which diagnostic tests are indicated?
X-ray: free air under diaphragm or in
lesser sac in an upright CXR (if upright
CXR is not possible, then left lateral
decubitus can be performed because air
can be seen over the liver and not
confused with the gastric bubble)
What are the associated lab findings?
Leukocytosis, high amylase serum
(secondary to absorption into the blood
stream from the peritoneum)
What is the initial treatment?
NPO: NGT (↓ contamination of the
peritoneal cavity)
IVF/Foley catheter
Antibiotics/PPIs
Surgery
What is a Graham patch?
Piece of omentum incorporated into the
suture closure of perforation
What are the surgical options for treatment of a duodenal perforation?
Graham patch (open or laparoscopic) Truncal vagotomy and pyloroplasty incorporating ulcer Graham patch and highly selective vagotomy
What are the surgical options for perforated gastric ulcer?
Antrectomy incorporating perforated
ulcer, Graham patch or wedge resection
in unstable/poor operative candidates
What is the significance of hemorrhage and perforation with duodenal ulcer?
May indicate two ulcers (kissing);
posterior is bleeding and anterior is
perforated with free air
What type of perforated ulcer may present just like acute pancreatitis?
Posterior perforated duodenal ulcer
into the pancreas (i.e., epigastric pain
radiating to the back; high serum
amylase)
What is the classic difference
between duodenal and
gastric ulcer symptoms as
related to food ingestion?
Duodenal = decreased pain
Gastric = increased pain
(Think: Duodenal = Decreased pain)
# Define the following terms: Graham patch
For treatment of duodenal perforation in
poor operative candidates/unstable
patients
Place viable omentum over perforation
and tack into place with sutures
Truncal vagotomy
Resection of a 1- to 2-cm segment of
each vagal trunk as it enters the
abdomen on the distal esophagus,
decreasing gastric acid secretion
What other procedure must
be performed along with a truncal vagotomy?
“Drainage procedure” (pyloroplasty, antrectomy, or gastrojejunostomy),
because vagal fibers provide relaxation of
the pylorus, and, if you cut them, the
pylorus will not open
# Define the following terms: Vagotomy and pyloroplasty
Pyloroplasty performed with vagotomy to
compensate for decreased gastric emptying
Vagotomy and antrectomy
Remove antrum and pylorus in addition
to vagotomy; reconstruct as a Billroth
I or II
What is the goal of duodenal
ulcer surgery?
Decrease gastric acid secretion (and fix IHOP)
What is the advantage of
proximal gastric vagotomy
(highly selective
vagotomy)?
No drainage procedure is needed; vagal fibers to the pylorus are preserved; rate of dumping syndrome is low
What is a Billroth I (BI)?
Truncal vagotomy, antrectomy, and
gastroduodenostomy (Think: BI ONE
limb off of the stomach remnant)
What are the contraindications for a Billroth I?
Gastric cancer or suspicion of gastric cancer
