Upper GI Surgery JC052: Profuse Vomiting Of Fresh Blood And In Shock: Severe Upper GI Bleeding

Question 1

Presentations of Severe GI bleeding

Answer 1

1. Fresh blood vomiting (Haematemesis)
2. Coffee ground vomiting (***Methaemoglobin: conversion of Hb by gastric acid —> colour change)
   - usually indicate less severe bleeding / bleeding stopped
3. Melena / Tarry stool (***Haematin: conversion of Hb by bacteria —> black colour)
   - Old melena: black only
   - Fresh melena: red + black —> large amount of blood (some converted to Haematin some didn’t)
4. Fresh PR bleed (***Haematochezia: no conversion by bacteria ∵ quick passage of blood in GI tract)
   - bear in mind haemorrhoids more common for fresh PR bleeding (well without haemodynamic disturbance)
5. Occult bleed (low degree of bleeding apart from ***Symptoms of Anaemia)

Severe: 1, 3, 4

Question 2

***Causes of upper GI bleeding (記)

Answer 2

記: 潰瘍, 發炎, 嘔, 靜脈曲張, 腫瘤, 手術, 流血不止, Angiodysplasia, Dieulafoy’s lesion

Descending order of frequency (***: more likely severe):

1. **Duodenal / Gastric ulcer
   - big vessel may be eroded —> **arterial bleeding
2. Gastritis
   - haemorrhagic gastritis
   - related to stress e.g. severe burn, head injury
   - diffuse edema of mucosa + haemorrhage
3. **Esophageal / Gastric varices
   - portal hypertension —> varices formation —> too high pressure (10 mmHg) —> burst and severe haemorrhage
   - big veins may be eroded —> **venous bleeding
4. Mallory-Weiss syndrome
   - vomiting: initial vomitus only gastric content —> sudden vomiting tears mucosa in GEJ —> bleeding
   - tear small vessel —> self-limited bleeding (massive bleeding rare)
   - vomiting followed by haematemesis / coffee ground vomiting
5. Benign / Malignant tumour
   - carcinoma
   - gastrointestinal stromal tumour (GIST)
6. Esophagitis / Esophageal tumour
7. ***Stomal ulcer
   - anastomotic ulcer after partial gastrectomy
8. ***Aortoduodenal fistula
   - abnormal connection between abdominal aorta and duodenum (rare), result of graft repair of previous AAA —> infection —> inflammation + erosion of graft into duodenum
9. Haemobilia (bleeding into bile duct), Haemosuccus pancreaticus (bleeding into pancreatic duct ∵ haemorrhagic pancreatitis)
10. Vascular malformation, Angiodysplasia
    - can occur anywhere in GI tract
11. **Dieulafoy’s lesion
    - abnormal **artery penetrating through stomach wall into proximal stomach —> bleed —> vessel retract back to submucosal layer —> non-visible after bleeding episode (∴ difficult to diagnose)
12. Duodenal / Jejunal diverticulum, Jejunal ulcer
    - diverticulum: congenital / acquired
    - Jejunal ulcer: NSAIDs, steroids, aspirin, infection from CMV, irradiation

Question 3

Gastric ulcer approach

Answer 3

1. Biopsy at ulcer site
   - exclude malignancy
   - biopsy until ulcer healed (to avoid sampling error) (SpC Revision)
2. Biopsy at antrum
   - check for H. pylori infection
   —> Invasive test (Rapid urease test, Gram smear, Culture and sensitivity)

Question 4

History taking

Answer 4

1. Nature, Rate, Duration of bleeding
   - Haematemesis, Coffee ground, Melena, Fresh PR bleeding
2. Previous episodes
   - Previous ulcer disease —> cirrhosis —> variceal bleeding instead (on 2nd presentation)
3. Pain
   - may not be present (cannot exclude ulcer, ∵ ulcer may not cause pain)
4. Weight loss, Anorexia
   - underlying malignancy
5. Medical conditions, Liver disease, HBsAg, Hep B / C status, Bleeding tendency
   - **portal hypertension (ulcer still more common cause of bleeding than variceal bleeding)
   - **bleeding tendency: can cause minor bleeding into major bleeding
6. History of irradiation
   - Enteritis
7. Alcohol
   - chronic liver disease
8. Drug history (as a cause / aggravating factor)
   - aspirin / NSAIDs
   - anticoagulant (e.g. warfarin)
   - antiplatelet (e.g. aspirin, clopidogrel)
   - cardiac drugs (e.g. β-blocker) —> **mask haemodynamic response (e.g. tachycardia in response to bleeding)
   - **iron —> black stool (but normal consistency: vs Melena: Liquid / Gel-like consistency)

Question 5

S/S in P/E

Answer 5

1. Pallor, Tachycardia, Hypotension
   - pallor: usually not obvious
   - ***tachycardia: most useful sign for major active bleeding
   - hypotension: late sign for massive bleeding
2. Cervical LN
   - upper GI malignancy
3. S/S of Chronic liver disease
4. Portal hypertension
   - Caput medusae
   - Splenomegaly
   - Ascites: Shifting dullness
5. Abdominal tenderness
   - Peritonitis
6. Abdominal mass
   - reason of bleeding (e.g. tumour)
7. PR exam
   - fresh / old melena

Question 6

Management principles of GI bleeding

Answer 6

1. Resuscitation
   - early recognition of shock
   - ***Tachycardia: earliest sign (Hypotension: late sign)
2. Diagnosis
   - history
   - P/E
   - investigations
3. Treatment
4. Monitoring

Question 7

***1. Resuscitation

Answer 7

1. Secure ***ABC
2. ***Nil by mouth, NG tube in unconscious, aspiration risk patients
3. ***Large bore IV cannula (give IV fluid at a fast rate)
4. Volume replacement: Colloids / **Crystalloids, **Group O Rh-ve blood (in extreme cases)
5. ***Type + screen
6. ***Hb level, CBP, Platelet (for coagulopathy), PT/APTT, LRFT (renal failure patients may be anaemic at baseline)
7. ***Erect CXR (on suspicion of aspiration / peritoneal signs / perforation)

Question 8

4. Monitoring

Answer 8

Vitals (記 TURBO-P: Temp, Urine, RR, BP, O2, Pulse)
1. Shock chart hourly (document observations every hour)
2. BP, pulse
3. RR, SaO2 (for aspiration, end-organ perfusion)
4. Core temperature (clotting best function in normal temperature, avoid coagulopathy associated with hypothermia due to volume replacement / blood loss)
5. **Urine output (>=0.5 ml/kg/hour) (indicator of end-organ perfusion)
6. **Central venous pressure (CVP) (avoid congestive HF)
7. Cardiac monitor

Question 9

2. Diagnosis

Answer 9

• Ulcer bleed usually stops spontaneously (70-80%)
  —> identify 20% patient with ongoing bleeding
• Identify patient in shock (e.g. tachycardia)
• Identify patient with ongoing bleeding

General guideline:
Ulcer bleeding
—> Bleeding stopped (80%) —> History, P/E, Investigation

—> Ongoing bleeding (20%)
—> Shock —> **Resuscitation —> Rapid assessment + **Endoscopy
—> No Shock —> Rapid assessment + Endoscopy

Question 10

Features suggestive of ongoing bleeding

Answer 10

Any 1 of following:
1. Haematemesis
2. Fresh blood aspirated from NG tube
3. Fresh PR bleeding
4. ***Tachycardia
5. Fresh melena
—> Endoscopic therapy should be offered asap

Question 11

Role of upper endoscopy

Answer 11

1. Verify bleeding source
2. ***Stratify risk of re-bleeding
3. ***Therapy
   - definitive
   - temporising

Question 12

Endoscopic Stigmata of Recent Haemorrhage (ESRH)

Answer 12

***Forrest’s classification (Re-bleeding risk):
1a: Spurting —> 80-90%
1b: Oozing —> 30%
2a: Non-bleeding visible vessel —> 20-50%
2b: Adherent clot —> 20-30%
3: Clean —> 0-2%

Question 13

Acute treatment

Answer 13

Depends on diagnosis

Bleeding peptic ulcer
1. Clean base: start feeding, early discharge

2. Therapeutic endoscopy
   - Injection method: **Adrenaline (around bleeding vessel: **pressure effect / tamponade / **vasoconstrictive effect, attract platelet for **thrombosis)
   - Thermal method: **Heater probe
   - Mechanical method: **Metal clip
   (- Spray method: Nanopowder)
3. H2 blocker, PPI
   - ***quicken healing of ulcers
   - PPI infusion

Question 14

After therapeutic endoscopy

Answer 14

1. Close monitoring
2. Look out for re-bleeding (first ***3 days)
3. Signs of possible re-bleeding
   - Haematemesis
   - Fresh blood aspirated from NG tube
   - Fresh PR bleeding
   - Tachycardia
   - Fresh melena
   - ↓ Hb level
   —> Small re-bleeding —> **2nd Endoscopy
   —> Large re-bleeding —> **Surgical intervention

Question 15

***Risk factors for Recurrent bleeding

Answer 15

1. Shock on presentation
2. Low Hb (<8) on presentation
3. Transfusion
4. Age >60 yo
5. Comorbidity
6. Coagulopathy
7. Initially already hospitalised
8. Large ulcer
9. Ulcer on **Higher posterior lesser curve: **Left gastric artery (direct branch from Celiac artery)
10. Ulcer on **Posterior D1: **Gastroduodenal artery (massive bleeding)

Question 16

Surgery for bleeding ulcers

Answer 16

***Plication of bleeder (through suturing) + Additional procedure

Indications:
- Therapeutic endoscopist not available
- Massive bleeding
- Failed endoscopic therapy
- Rebleed after endoscopic therapy

Question 17

Choice of additional procedure

Answer 17

1. Condition of patient
2. Experience of surgeon
3. Type of ulcer
   - GU: **Ulcer excision, **Partial gastrectomy (if malignant): Billroth 1 / 2 reconstruction
   - DU: **Vagotomy (long term control of acid production) + **Pyloroplasty + ***Plication

Vagotomy:
- Truncal: divide 2 vagal trunks around distal esophagus
—> innervate Pylorus as well (to relax Pylorus)
—> if removed: constant spasm of Pyloric sphincter —> ***Pyloroplasty (divide pyloric muscle —> avoid blockage of gastric outlet)

Question 18

Ulcer perforation (SpC Revision)

Answer 18

• Perforated GU / DU
• ~20% no free gas on erect CXR —> CT abdomen

Treatment:
- Perforated GU: **Ulcer excision / Partial gastrectomy
- Perforated DU: Surgery: **Omental patch repair (Laparoscopic)

Question 19

Gastric polyp

Answer 19

1. Fundic gland polyp (most common)
   - located at fundus + body of stomach
   - 2-3mm in size
   - Fundic gland polyposis: a condition of multiple of fundic gland polyps —> can be sporadic / associated with **FAP —> **Colonoscopy to exclude FAP
2. Hyperplastic polyp
   - mostly benign, little proportion malignant
3. Adenomatous polyp
   - can be malignant, esp. >2cm, sessile in morphology
   - rare
4. Harmatomatous polyp
5. Inflammatory polyp
6. Others

Question 20

Gastrointestinal stromal tumour (GIST)

Answer 20

• Tumour arising from muscularis propria
• Location: Stomach (70%, esp. proximal stomach), other parts of GI tract
• Marker: c-kit (CD117), CD34 (SpC PP)

Clinical features:
- GI bleed

Risk stratification for progressive disease:
- **Armed Forces Institute of Pathology (AFIP), based on:
1. **Mitosis
2. **Size
3. **Location (Risk: Large bowel > Small bowel > Duodenum > Stomach (lowest risk of progressive disease))

Diagnosis:
- EUS

Treatment:
- Surgery (symptomatic / size >2cm)
- Imatinib mesylate (Gleevec) (for metastasis)

Question 21

Foreign body ingestion

Answer 21

• Fish bone (most common) (Radiolucent, cannot be detected by X-ray) > Chicken bone
• ~80% lodged at / above Cricopharyngeus
• ~60-70% passed spontaneously

Complications:
- **Perforation
- **Abscess
- ***Aortoesophageal fistula (fatal) —> Severe pain, Fever, Chills, Surgical emphysema, Tenderness at neck, Bleeding

P/E:
- S/S of complications

Diagnosis:
- Lateral neck X-ray
—> Thickness of soft tissue e.g. Cricopharyngeus (UES) at C6 level —> Thicker than vertebral body
—> Free gas anterior to vertebral body
- Endoscopy (to make sure bone has passed)

Question 22

Esophageal perforation

Answer 22

• Free gas anterior to vertebral body

Management:
Stable: Observation
Unstable:
1. Fast
2. IV fluid
3. Monitor vitals
4. Tubes (e.g. Foley)
5. Drugs (e.g. IV Antibiotics)
6. Investigations
7. Other treatment

Question 23

GI bleeding of obscure origin

Answer 23

GI bleeding but cannot identify bleeding source on upper + lower endoscopy

3 situations:
1. Active bleeding, unstable haemodynamic / shock
- **Immediate surgery to examine whole GI tract externally
- **On-table enteroscopy to look at lumen internally

2. Active bleeding, stable
   - **Angiogram (better if more active / significant bleeding, more specific)
   - **RBC scan (more sensitive if slower rate of bleeding)
3. Bleeding stopped
   - **Discharged, arrange investigations
   —> **Meckel’s scan in young patients for Meckel’s diverticulum
   —> **CT scan then **Capsule endoscopy (for smaller lesions) then ***Enteroscopy in older patients for tumour)
   —> attend A/E asap to arrange angiogram / RBC scan / surgery

Question 24

Bariatric surgery

Answer 24

Aim:
- Reduce long term morbidity + mortality associated with morbid obesity
- NOT cosmesis

General indications:
1. Asian
- BMI >32 with comorbidities
- BMI >35

2. Caucasians
   - BMI >35 with comorbidities
   - BMI >40

Types:
1. Restrictive (reduce capacity of stomach)
2. Malabsorptive (induce malabsorption)
3. Combined

Methods:
1. Laparoscopic adjustable gastric banding
- out of favour

2. Laparoscopic sleeve gastrectomy
   - gaining popularity
   - restrictive (self notes)
3. Laparoscopic roux-en-Y gastric bypass
   - not preferred in some countries where gastric cancer is prevalent e.g. Japan —> difficulty to screen parts of stomach with endoscopy after surgery for gastric cancer
   - combined restrictive + malabsorptive

Question 25

Upper endoscopy + therapy

Answer 25

Indications:
1. Diagnostic
2. Therapeutic
- Haemostasis (ulcers, varices)
- Removal of foreign body
- Feeding (feeding tube insertion, PEG)
- Relieve obstruction (dilatation, stenting (SEMS))
- Resection (polypectomy, EMR, ESD)
- Ablation (RFA for Barrett’s dysplasia, cryotherapy)
- POEM for Achalasia (increase chance of GERD)
- Bariatric endoscopy (intragastric balloon (temporary measures), gastroplasty (suturing of gastric wall))
- EUS guided therapy (e.g. drainage of pseudocysts)