Hemorragia Digestiva

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Objectives : 

Objectives Follow the changing patterns of the disease Outline the current scope of the problem Diagnostic and non-operative modalities Future management

UGI Hemorrhage : 

UGI Hemorrhage Approximately 30% decline in rate over last 15 years 150,000 admissions per year Over $1,000,000,000 annually Associated with NSAID use

UGI Hemorrhage : 

UGI Hemorrhage Mortality rate 8-10% >65 now comprise over 30% Peptic ulcer still most common cause Surgery now plays an adjunctive role

UGI Hemorrhage: 1985 : 

UGI Hemorrhage: 1985 40 y.o. man with known or suspected PUD Often significant co-morbidities (drugs, ETOH, etc.) Hematemesis and hypotension NGT placed and volume resuscitated

UGI Hemorrhage: 1985 : 

EGD reveals 1.5 cm DU with visible vessel 6 units PRBC transfused OR: oversewing and vagotomy and pyloroplasty Discharged home POD#4; F/U:?; uninsured:? UGI Hemorrhage: 1985

UGI Hemorrhage: 2005 : 

48 y.o. female s/p Roux-en-Y gastric bypass with subsequent revision One day h/o abdominal pain CT scan: pneumoperitoneum OR: perforated DU: Graham patch UGI Hemorrhage: 2005

UGI Hemorrhage: 2005 : 

POD #2: intermittent BRBPR Volume resuscitated Intermittently hypotensive Nuclear medicine: tagged RBC scan UGI Hemorrhage: 2005

UGI Hemorrhage: 2005 : 

Suspected bleed from transverse colon Bleeding continues Arteriogram performed X 2 UGI Hemorrhage: 2005

UGI Hemorrhage: 2005 : 

Occluded celiac axis Retrograde flow via inferior pancreatico-duodenal artery Fills hepatic, left gastric, splenic arteries Unable to embolize 2nd branch of IPDA UGI Hemorrhage: 2005

UGI Hemorrhage: 2005 : 

OR: duodenotomy with bleeding point third portion oversewn 20 units PRBC Fascia left open with vac sponge closure Fascia closed POD #4 UGI Hemorrhage: 2005

UGI Hemorrhage: 2005 : 

Prolonged ICU course (30 days) Transferred to rehab center day #45 Insurance: “pre-existing condition” UGI Hemorrhage: 2005

UGI Hemorrhage: 1985 : 

Personal experience 27 gastric resections 17 vagotomies 95th percentile UGI Hemorrhage: 1985

UGI Hemorrhage: 2005 : 

OU experience (15 chiefs, 2002-2005) 49 resections (3.3/resident) 26 operations for perforation(1.7/resident) 6 vagotomies (0.4/resident) 2 laparoscopic resections UGI Hemorrhage: 2005

UGI Hemorrhage: 1985: Literature : 

10 articles in 5 major journals “Management of Giant Duodenal Ulcer” “Risks of Surgery for UGI Hemorrhage: 1972 vs. 1982” “Improvements in the Diagnosis and Management of Aortoenteric Fistula” UGI Hemorrhage: 1985: Literature

UGI Hemorrhage: 1985: Literature : 

“Changing Patterns of Gastrointestinal Bleeding” “Recurrence After Parietal Cell Vagotomy” “Esophageal Transection Fails…Variceal Bleeding” “Topical Prostaglandin E2 in…UGI Hemorrhage” UGI Hemorrhage: 1985: Literature

UGI Hemorrhage: 2000’s: Literature : 

Only 3 references in same 5 journals “Rupture of Splenic Artery Pseudoaneurysms” “Modified Sugiura Procedure” “Effectiveness of Gastric Devascularization and Splenectomy…Gastric Varices” UGI Hemorrhage: 2000’s: Literature

UGI Hemorrhage: 2005: Literature : 

“Celiac Axis Ligation…Unmanageable UGI Hemorrhage” Arterial Embolization for Dieulafoy Bleeding” UGI Hemorrhage: 2005: Literature

UGI Hemorrhage: 1980’s : 

Mostly gastroduodenal ulcers Protocol: resuscitation, early endoscopy and operation 66 patients, 1986-1990 No deaths Bender, et al. Am Surg 1994 UGI Hemorrhage: 1980’s

UGI Hemorrhage: 1990What Changed? : 

Therapeutic endoscopy Discovery of the role of h. pylori Better acid suppression drugs Liver transplant Interventional radiology UGI Hemorrhage: 1990What Changed?

Helicobacter Pylori : 

Helicobacter Pylori First reported 1983 in mucosal biopsies of patients with active gastritis Initially debated about role in ulcer disease Abundant producer of urase Elicits robust inflammatory response

H. Pylori : 

H. Pylori Double therapy (antibiotic plus adjunctive agent) - no longer used Triple therapy (two antibiotics plus adjunctive agent) – current mainstay Quadruple therapy (two antibiotics plus two adjunctive agents) – resistant organisms “Cure” in 90% of compliant patients

Pharmacologic Therapy : 

Pharmacologic Therapy Oral antacids have no effect on bleeding H2- receptor antagonists have had 27 RCT’s on over 2500 patients Marginal improvement in surgery and death Still widely used Collins, et al. NEJM, 1985

Proton Pump Inhibitors : 

Proton Pump Inhibitors Appear to be effective at high doses Especially so with high risk patients Effects clouded by use of therapeutic endoscopy

Proton Pump Inhibitors : 

220 patients with UGI hemorrhage from PUD All underwent endoscopy - stigmata present Omeprazole 40 mg twice daily vs. placebo Patients in shock excluded Proton Pump Inhibitors

Proton Pump Inhibitors : 

Omeprazole (n=110) Control (n=110) p Rebleed 12 40 <0.001 Surgery 8 26 <0.001 Deaths 2 6 .20 Not effective in those with arterial bleeding Khuroo, et al. NEJM, 1997 Proton Pump Inhibitors

Proton Pump Inhibitors : 

240 patients with bleeding from PUD All received endoscopy with epinephrine injection and heater probe 80 mg bolus injection of omeprazole plus 8 mg/hr infusion Control groups received placebo Proton Pump Inhibitors

Proton Pump Inhibitors : 

Proton Pump Inhibitors Omeprazole (n=120) Control (n=120) p Rebleed 5 24 0.001 Surgery 3 9 0.14 Death 5 12 0.13 Omperazole also had shorter LOS and fewer units transfused Lau, et al. NEJM, 2000

Endoscopic Therapy : 

Endoscopic Therapy Widely accepted as most effective method Not only controls ulcer bleeding but prevents rebleeding Decreases need for surgery Only meta analysis shows decrease in deaths Cook, et al. Gastroenterology, 1992

Thermal Therapy : 

Thermal Therapy Laser (Argon and Nd: YAG) Monopolar electrocoagulation Bipolar or mulitpolar electrocoagulation Heater probe

Laser Therapy : 

Laser Therapy First shown to be effective Expensive and cumbersome Largely supplanted

Monopolar Electrocoagulation : 

Monopolar Electrocoagulation Effective with both bleeding and non-bleeding vessels Tissue adherence problems Unpredictable energy deposition ? Highest rate of perforation

Bipolar or Multipolar Electrocoagulation : 

Direct probe pressure to help in tamponade Large (3.2 mm) probe Low watt (15 to 25) setting Need prolonged period (7-10 seconds) Bipolar or Multipolar Electrocoagulation

Heater Probe : 

Heater Probe Produces thermal energy to coagulate tissue Direct pressure to help with tamponade 25 to 30 joule setting Repeated applications

Injection Therapy : 

Injection Therapy Epinephrine (1:10,000) Saline Absolute alcohol Water Sclerosing agents

Which Endoscopic Therapy? : 

Which Endoscopic Therapy? Injection, laser, multi- / bipolar and heater probe equivalent Latter three most common (simplest) Combination therapy not been shown more effective Rebleed rates 15-20%

Endoscopic Therapy - Questions : 

Lack of standardized definitions, especially in stigmata Complications: rebleeding, 20%; perforation, 1% Costs not defined Role of repeat endoscopy: planned vs. rebleeding Endoscopic Therapy - Questions

Future Endoscopic Therapies : 

Future Endoscopic Therapies Cryotherapy Clips Argon plasma coagulation Sewing

Adjunctive Therapies : 

Adjunctive Therapies Prokinetic agents Octreotide Dedicated units ? Earlier surgery

Second Look Endoscopy : 

Second Look Endoscopy Patients at high risk of rebleeding can be identified Age, site, size, co-existent disease Baylor Bleeding Score

Baylor Bleeding Score : 

Baylor Bleeding Score 1 point for each decade of life after 30 Up to 5 points for associated disease Up to 5 points for site and stigma of bleeding High risk of rebleeding with pre-endoscopy score of 5 or greater or post-endoscopy score of 10 or greater

Endoscopic vs. Operative Treatment : 

Endoscopic vs. Operative Treatment 55 patients (of 61) with arterial bleeding or visible vessel > 2 mm Repeated endoscopy in 24 hrs (32) or early operation (23) Gastric resection in 79% Rebleed: 48% endoscopy vs. 11% operation (p=0.002)

Endoscopic vs. Operative Treatment : 

22% required operation in endoscopy group Mortality: 6% endoscopy vs. 7% operation No subgroup or intent-to-treat analysis Early 1990’s Imhof, et al. Langenbecks Arch Surg, 2003 Endoscopic vs. Operative Treatment

“Modern” Management ofUGI Hemorrhage : 

“Modern” Management ofUGI Hemorrhage Resuscitation High dose proton pump inhibitors Early endoscopy with therapeutic intervention Repeat endoscopy in 2 hours for high risk patients

“Modern” Management ofUGI Hemorrhage : 

Concomitant decision by surgery and gastroenterology regarding operation Most deaths still due to repeated episodes of shock “Modern” Management ofUGI Hemorrhage

Operation for UGI Hemorrhage : 

Operation for UGI Hemorrhage Likely to become even less frequent Therefore operative mortality will likely increase No need to do a curative ulcer operation Control hemorrhage only

Future Directions : 

Future Directions Further risk stratification Define role of angiography Earlier operation for those at higher risk

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