LECTURE 7

Upper digestive hemorrhage

Upper gastrointestinal bleeding is defned as bleeding from a
source proximal to the ligament of Treitz.
The most common cause of upper GI hemorrhage is peptic ulcer. Approximately 20%
of patients with peptic ulcer will bleed. It is likely that with !. pylori eradication and proton
pump inhibitor therapy the incidence of bleeding will decrease. "ot all bleeding from ulcer is
acute or massi#e. Indeed some patients present with iron$deficiency anemia from occult
blood loss.%hen acute hemorrhage occurs patients present with hematemesis and&or melena.
Infre'uently massi#e bleeding from a duodenal ulcer presents as lower gastrointestinal
hemorrhage without hematemesis. If the bleeding is rapid the blood issuing rectally may be
red rather than black.
(ome )0% of patients admitted with upper GI hemorrhage from an ulcer stop bleeding
spontaneously within * hours of admission to a hospital. +f the remainder about half are
successfully treated endoscopically with in,ection therapy or with heater$probe or laser
coagulation. The rare patient has such an exsanguinating hemorrhage that immediate
operation and control of bleeding is necessary before #olume resuscitation can be ade'uately
accomplished.
I. Causes of Upper Gastrointestinal Hemorrhage
The most important causes-
Duodenal ulcer
Gastric ulcer
Diffuse erosive gastritis
Esophageal or gastric varices
allor!"#eiss tear of the gastroesophageal $unction
Gastric carcinoma
%rteriovenous malformations
The history should include information about pre#ious episodes of gastrointestinal bleeding -
bleeding current medications .e.g. aspirin or warfarin use/ and related diseases .e.g.
hematologic disorders alcoholism peptic ulcer disease and recent episodes of #omiting/.
The causes for upper GI hemorrhage include the following-
0sophageal causes-
o 0sophageal #arices
o 0sophagitis
o 0sophageal cancer
o 0sophageal ulcers
1
Gastric causes-
o Gastric ulcer
o Gastric cancer
o Gastritis
o Gastric #arices
o Gastric antral #ascular ectasia or watermelon stomach
o 2ieulafoy3s lesions
2uodenal causes-
o 2uodenal ulcer
o 4ascular malformations including aorto$enteric fistulae. 5istulae are usually
secondary to prior #ascular surgery and usually occur at the proximal
anastomosis at the third or fourth portion of the duodenum where it is
retroperitoneal and near the aorta.
o !ematobilia or bleeding from the biliary tree
o !emosuccus pancreaticus or bleeding from the pancreatic duct
II. T!pes of &leeding
Hematemesis is the #omiting of blood that is either bright red or resembling coffee
grounds in appearance. !ematemesis usually indicates a bleeding source proximal to
the ligament of Treit6. 7offee$grounds hematemesis indicates that the blood has been
in contact with gastric acid long enough to become con#erted from hemoglobin to
methemoglobin.
Hematoche'ia is the passage of bright red blood by rectum. Although it indicates GI
bleeding it does not specify the le#el within the GI tract.
elena is the passage of black usually tarry stools. Although melena signifies a
longer time within the GI tract than bright red blood it does not guarantee that the
bleeding is from the upper tract.
8lood mixed with stool and mucus can produce a characteristic $ell!li(e stool. This
may originate from a 9eckel3s di#erticulum particularly in children
III. )!mptoms and signs
epigastric pain
abdominal tenderness:
acute hemorrhage causes hematemesis or hematoche6ia hypotension or shock:
chronic hemorrhage causes weakness
anemia
fecal occult blood
;atients with upper gastrointestinal hemorrhage often present with hematemesis coffee
ground #omiting melena maroon stool or hematoche6ia if the hemorrhage is se#ere. The
presentation of bleeding depends on the amount and location of hemorrhage.
2
;atients may also present with complications of anemia including chest pain syncope
fatigue and shortness of breath.
The physical examination performed concentrates on the following things-
4ital signs in order to determine the se#erity of bleeding and the timing of
inter#ention
Abdominal and rectal examination in order to determine possible causes of
hemorrhage
Assessment for portal hypertension and stigmata of chronic li#er disease in order to
determine if the bleeding is from a #ariceal source.
I*. Diagnosis
The cause and the location of the bleeding must be confirmed unless imminent exsanguination
calls for immediate measures In less urgent circumstances once the patient has been
stabili6ed one may continue with diagnostic procedures.
+. ,i&eroptic endoscop! of the upper GI tract has become the optimal
diagnostic procedure because it allows direct #isuali6ation of the lesion.
0arly detection of the source of bleeding is a key step in management. The best way to
identify the source is with upper GI endoscopy. The ideal time to perform this examination is
.1/ when the patient is hemodynamically stable and
.2/ when the nasogastric aspirate following irrigation is pink.
0ndoscopy identifies the site of bleeding in about )0% of patients with upper GI
bleeding. The esophagus is easily ruled out as the site of bleeding.
<esions in the stomach may be obscured by blood clot but e#en then with persistence and
expertise the entire stomach can be examined satisfactorily.
8leeding from duodenal ulcer may be e#idenced by the presence of
.1/ acti#e bleeding from a posterior ulcer crater:
.2/ a #isiblebleeding #essel:
.=/ a #isible nonbleeding #essel with clot: or
.>/ an adherent fresh clot at ulcer base.
o 0ndoscopy allows-
2etermination of the si6e and number of lesions in most cases .lesions
are multiple in 1?% of cases/
Assessment of which site is acti#ely bleeding
Assessment of the rate of bleeding. 5or example if an arterial #essel is
#isibly bleeding in the base of a large duodenal ulcer then there is a
good chance that it will not stop bleeding.
2istinction between an ulcer #arices gastritis and a tear in the
esophagus .9allory$%eiss syndrome/ that follows forceful #omiting
2etermination of whether a lesion is benign or malignant
o 0ndoscopy is only safe if the patient@s #ital signs are relati#ely stable. (edation
is dangerous because it increases the risk of #omiting followed by aspiration of
the gastric contents into the pulmonary bed. (edation is dangerous because it
increases the risk of #omiting followed by aspiration of the gastric contents
into the pulmonary bed.
=
-. Upper GI series helps to define anatomy or pathology more completely but
unfortunately it sheds little light on the relationship of a particular lesion to the
hemorrhage.
.. /assage of a nasogastric tu&e aids considerably in determining that the source of
bleeding is proximal to the ligament of Treit6.
0. %ngiograph! and radionuclide scanning may occasionally help to locate the site of
bleeding but both procedures are more useful in lower GI hemorrhage.
Angiography has a role but not a fre'uent one in the early detection of the site of
hemorrhage. 8leeding has to occur at the rate of 2m<&min or more for the test to succeed. It is
most useful when endoscopy has failed to identify the cause of bleeding. +n occasion when
bleeding is massi#e and a nonsurgical treatment approach is chosen angiography can be
useful not only in identifying the bleeding #essel but also in controlling bleeding by selecti#e
emboli6ation.
*. Resuscitation aspects of upper digestive hemorrhage patient
Initial resuscitation should be accomplished 'uickly. If there is any 'uestion about the
patient@s le#el of consciousness the airway must be protected with endotracheal intubation. In
most circumstances such drastic action is unnecessary.
In the initial sur#ey the patient should also be carefully examined for any stigmata of
chronic li#er disease and oral mucosal hemangiomas.
Auickly two large$bore intra#enous catheters should be inserted as well as a
nasogastric tube and a 5oley catheter.
A blood sample is obtained for complete blood count .787/ blood urea nitrogen
.8B"/ electrolyte le#els and for a crossmatch of > to C units.
The speed and type of fluid resuscitation depends on the hemodynamic status of the
patient. 9ost patients are moderately hypotensi#e and the initial resuscitation can be
successfully accomplished with crystalloids .saline or lactated Dinger@s solution/.%hen
hypotension is extreme howe#er immediate blood transfusion should be gi#en using either
group specific Dh$negati#e or +$negati#e blood. (ome se#erely hypotensi#e patients can be
successfully resuscitated 'uickly with colloids .plasma albumin or !espan/ until fully
crossmatched blood is a#ailable.
%hen the patient is hemodynamically compromised central #enous pressure
monitoring or preferably pulmonary artery pressure monitoring is necessary. The goal of
resuscitation is to rapidly restore circulating #olume and ade'uate urine output .E?0 m<&h/
and to establish monitoring of #ital signs urine output and central #enous or pulmonary
arterial wedge pressure measurements.
Aspiration should be pre#ented by insertion of either a large nasogastric tube or an
0wald tube. The stomach is e#acuated and la#aged with water or saline. %hen large amounts
of blood are transfused it is necessary to monitor coagulation factors .e.g. platelets
prothrombin time/ and #itamin F administration may be necessary.
>
*I. edical treatment
If treated expeditiously in a systematic fashion the patient with upper GI hemorrhage has an
excellent chance for reco#ery. Treatment is aimed at supporting the patient3s #ital signs as well
as stopping the hemorrhage. Desuscitation measures should begin immediately when the
patient is first seen.
9edical treatment of aggra#ating factors can then begin.
o A nasogastric tube is inserted and the residual thrombus in the stomach is
remo#ed with an iced saline solution.
o 7lotting factors. Any clotting abnormalities are corrected with appropriate
factors
5resh fro6en plasma if the prothrombin time is abnormal
;latelets if thrombocytopenia is present
4itamin F if bleeding is from esophageal #arices
o !istamine
2
.!
2
/ antagonists proton pump inhibitors .;;I/ and antacids. An
aggressi#e regimen is begun. !
2
antagonists gi#en as a continuous infusion are
commonly used in this setting. +ral antacids with gastric p! monitoring also
ha#e been used.
o 4asopressin a powerful #asoconstrictor may be useful.
It can be infused through a peripheral #ein at a rate of up to 1 B&minute
or it can be infused directly into the bleeding #essel by means of It can
be infused through a peripheral #ein at a rate of up to 1 B&minute or it
can be infused directly into the bleeding #essel by means of
angiography.
4asopressin temporarily controls bleeding in G?% of patients: by
contrast bleeding was stopped in =0% of patients treated
con#entionally without #asopressin. !owe#er #asopressin is
contraindicated in patients with significant coronary artery disease
because of coronary #asoconstriction.
o 5iberoptic endoscopy in addition to being a diagnostic procedure may also be
useful when esophageal #arices are to be sclerosed .see 7hapter 1> II 0/ or
small bleeding sites are to be coagulated.
o Angiography similarly may be a therapeutic aid. It allows bleeding from small
#essels to be controlled either by emboli6ation of the bleeding #essel or by
intra$arterial administration of #asopressin.
o 8alloon tamponade can be important in controlling bleeding from #arices.
Control of 1leeding
As indicated earlier )0% of patients stop bleeding spontaneously within * hours of admission
to a hospital and can be managed conser#ati#ely.
If bleeding persists control with the aid of endoscopy can be achie#ed with-
coagulation .e.g. heater probe laser/
endoscopic sclerotherapy or
by endoscopic in,ection of alcohol or adrenaline.
?
*II. )urgical treatment
The following indications for surgery for the patient with a bleeding ulcer are generally
accepted-
1. 0xsanguinating hemorrhage when 'uick resuscitation is difficult.
2. 5ailure of control of hemorrhage with endoscopic based methods.
=. Debleeding that begins again while the patient is under treatment in a hospital after initial
cessation. .This circumstance nearly always suggests bleeding from a gastroduodenal artery./
0#en here it is reasonable to attempt endoscopic control before surgery if the patient is stable
and&or at high risk for surgery.
>. <oss of C units of blood or more where endoscopic therapy is una#ailable or cannot be
performed.
The principles of surgery in a bleeding peptic ulcer are to control bleeding and perform a
definiti#e ulcer operation. ;referred options are a#ailable when the site of bleeding can be
identified as either a duodenal or a gastric ulcer. %hen the site of bleeding is uncertain a
distal gastrotomy is first performed so that it can be extended into the duodenum if necessary.
%. )urger! for 1leeding Duodenal Ulcer
If a duodenal ulcer is identified as the cause of bleeding the two surgical options are
.1/ truncal #agotomy pyloroplasty and suture control of bleeding or
.2/ duodenotomy suture control of bleeding and proximal gastric #agotomy.
In the elderly or unstable patient the first option is more appropriate and the second option in
the young and stable patient.
The techni'ue of controlling a bleeding duodenal ulcer with sutures is illustrated in
5igure 1. "onabsorbable 00 sutures on a stout needle are used. Interrupted sutures are placed
at the proximal and distal parts of the ulcer and tied. This may control all or most of the
bleeding. Then a B$stitch is used as shown in the figure to ligate branches of the
gastroduodenal artery. Additional sutures including figure$* sutures may be needed to arrest
the bleeding completely. If these techni'ues fail to completely control the bleeding the
gastroduodenal artery must be dissected outside the duodenum as it branches off the hepatic
artery and ligated in continuity using 0$silk suture.
In se#ere chronic duodenal ulcer disease with ad#anced scarring and foreshortening of
the first part of the duodenum the application of sutures to control bleeding from the ulcer
bed poses a potential risk to the common bile duct. If the risk is considered high it is prudent
to perform choledochotomy and lea#e a red rubber catheter in the 782 until after the
hemostatic sutures are tied. At this point the surgeon can ascertain whether the catheter is
freely mo#able indicating that no ligation of the duct has occurred. The choledochotomy is
then closed o#er a T$tube.
C
5igure 1. (uture control of bleeding ulcer re'uires the
ligature of se#eral branches of the gastroduodenal artery in
the base of the ulcer. +ne techni'ue uses the B$shaped suture
as shown in the diagram.
1. )urger! for 1leeding Gastric Ulcer
Although a bleeding gastric ulcer can be treated by underrunning the bleeding point and
performing truncal #agotomy and pyloroplasty the preferred surgical approach is to perform a
distal gastrectomy that remo#es the ulcer.
%hen the ulcer is higher up on the lesser cur#ature of the stomach a slee#e
resection of the lesser cur#ature may be performed encompassing the ulcer.
%hen the ulcer is #ery high and near the gastroesophageal ,unction the
9adlener procedure may be used. This procedure which has been successfully utili6ed in the
past in#ol#es underrunning with sutures to control bleeding a four$'uadrant biopsy to rule
out carcinoma and a distal gastrectomy to treat the ulcer diathesis.
If the surgeon can ascertain intraoperati#ely that the ulcer is !. pyloriHassociated the
gastrectomy may be a#oided and eradication therapy administered postoperati#ely. At the
present time because no data are a#ailable to support this theoretical approach it is not
recommended.
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