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    Dynamic Practice Guidelines For Emergency General Surgery

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    Jolaine Vallo
    Upper gastrointestinal hemorrhage can range from slow intermittent bleeding to life-threatening hemorrhage. Risk assessment tools can help predict re-bleeding risk and mortality. Hemodynamically unstable patients require resuscitation before endoscopy. Endoscopy within 24 hours is recommended to identify the source, with endoscopic therapy offered for actively bleeding or visible vessels. Surgery is considered if bleeding cannot be controlled after a maximum of two endoscopies.

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    Dynamic Practice Guidelines For Emergency General Surgery

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    Jolaine Vallo
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    Upper gastrointestinal hemorrhage can range from slow intermittent bleeding to life-threatening hemorrhage. Risk assessment tools can help predict re-bleeding risk and mortality. Hemodynamically unstable patients require resuscitation before endoscopy. Endoscopy within 24 hours is recommended to identify the source, with endoscopic therapy offered for actively bleeding or visible vessels. Surgery is considered if bleeding cannot be controlled after a maximum of two endoscopies.

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    ACS-Handbook-CPG-Ch-10-Upper-GI-Hemorrhage

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    Upper gastrointestinal hemorrhage can range from slow intermittent bleeding to life-threatening hemorrhage. Risk assessment tools can help predict re-bleeding risk and mortality. Hemodynamically unstable patients require resuscitation before endoscopy. Endoscopy within 24 hours is recommended to identify the source, with endoscopic therapy offered for actively bleeding or visible vessels. Surgery is considered if bleeding cannot be controlled after a maximum of two endoscopies.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    132 views19 pages

    Dynamic Practice Guidelines For Emergency General Surgery

    Uploaded by

    Jolaine Vallo
    Upper gastrointestinal hemorrhage can range from slow intermittent bleeding to life-threatening hemorrhage. Risk assessment tools can help predict re-bleeding risk and mortality. Hemodynamically unstable patients require resuscitation before endoscopy. Endoscopy within 24 hours is recommended to identify the source, with endoscopic therapy offered for actively bleeding or visible vessels. Surgery is considered if bleeding cannot be controlled after a maximum of two endoscopies.

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    of 19

    20 Dynamic Practice Guidelines

    for Emergency General Surgery


    18 Committee on Acute Care Surgery, Canadian Association of General Surgeons
    10 UPPER GASTROINTESTINAL
    HEMORRHAGE
    Dynamic Practice Guidelines for Emergency General Surgery
    Neil Parry MD FRCSC FACS, Jed Scharf MD FRCSC,
    Sandy Widder MD FRCSC FACS MHA MSc QIPS
    Committee on Acute Care Surgery, Canadian Association of General Surgeons
    Clinical Practice Guideline
    UPPER GASTROINTESTINAL HEMORRHAGE
    SUSPECTED UPPER GASTROINTESTINAL HEMORRHAGE

    Hemodynamic instability?

    No Yes

    Upper GI Endoscopy
    1. Resuscitate
    within 24 hours
    2. Initiate Pharmacotherapy
    3. Arrange for Emergent Upper
    Source identified? GI endoscopy
    4. Surgical and interventional
    radiology consultation if upper
    No Yes
    endoscopy unsuccessful

    Colonoscopy to Specific
    assess for Lower Treatment based Source identified?
    GI Bleeding on etiology
    No Yes
    Source identified?
    Colonoscopy to Specific
    No Yes assess for Lower Treatment based
    GI Bleeding on etiology
    Evaluate for Small
    Bowel Bleed
    UPPER GI HEMORRHAGE Return to CPG

    Overview:
    • Defined as bleeding from a source proximal to the ligament of Treitz
    • Most common cause: Peptic ulcer disease (H. pylori ± NSAID related)
    • Other causes include:
    o Esophagogastric varices
    o Arteriovenous malformation
    o Tumor
    o Esophageal (Mallory-Weiss) tear
    o Vascular enteric fistula (uncommon but important to consider)
    • Spectrum from slow intermittent bleed to brisk life threatening
    hemorrhage
    • General surgeons tend to manage the more life threatening bleeds
    UPPER GI HEMORRHAGE Return to CPG

    Risk Assessment:
    • Risk assessment/scoring tools can be used to predict re-bleed rate and
    mortality (more useful for hemodynamically stable patients
    • Glasgow-Blatchford, Rockall and Addenbrooke scores incorporate
    biochemistry, patient co-morbidities and endoscopic findings
    o Helpful in determining who needs endoscopy or admission
    • Essentially, the following are associated with increased risk of re-
    bleeding and mortality:
    o Tachycardia (heart rate >100bpm)
    o Hypotension (blood pressure <100mmHg)
    o Age >60
    o Significant co-morbidities
    o Active bleeding/visible vessel on endoscopy

    Royal College of Physicians UK. 2012. NICE Clinical Guidelines


    UPPER GI HEMORRHAGE Return to CPG

    Resuscitation
    • Early consultation with intensive care is prudent
    • Hemodynamically unstable patients should be resuscitated in a
    monitored setting
    • Airway often needs to be definitively controlled
    • Transfuse blood, platelets and clotting factors as per local massive
    transfusion protocols. A level one infuser can be used to warm and
    rapidly administer blood products
    • Target hemoglobin of 70 – 90g/L*
    • Correct all coagulopathies (including low fibrinogen) – should not delay
    endoscopy however
    • Other: IV erythromycin (prokinetic) and IV proton pump inhibitor for
    patients with active nonvariceal upper gastrointestinal hemorrhage

    Villanueva C et al, 2013. NEJM


    UPPER GI HEMORRHAGE Return to CPG

    Variceal Bleed
    • Prophylactic antibiotics (Ceftriaxone or a Fluoroquinolone) should be
    offered to known cirrhotics.
    • Somatostatin or analogues are given to cause splanchnic
    vasoconstriction.
    • Vasopressin is generally not used as a splanchnic vasoconstrictor due to
    its significant systemic side effects – synthetic analogue, terlipressin, can
    be used as it has longer biologic activity and fewer side effects.
    UPPER GI HEMORRHAGE Return to CPG

    Endoscopy
    • Should be performed immediately after, or even during resuscitation in
    any hemodynamically unstable patient with massive upper
    gastrointestinal bleeding.
    • Otherwise, should be performed within 24 hours of admission for any
    acute upper gastrointestinal bleed.
    • Endoscopic treatment modalities include injection/spray (adrenaline,
    thrombin), thermal (electrocautery) and mechanical (clips, bands).
    • Ideally the surgeon will be present during endoscopy if not the primary
    operator in order ascertain the etiology and location of the bleed, while
    in addition expediting transfer to the operating theatre is case of
    endoscopic failure .
    Continue to Further Endoscopy
    UPPER GI HEMORRHAGE Return to CPG

    Endoscopy
    • Endoscopic therapy should be offered if actively bleeding vessel, non
    bleeding visible vessel and/or adherent clot are seen. Adherent clots
    are removed in order to determine and manage the source of bleeding.
    • Combination therapy with adrenaline is superior to adrenaline alone for
    nonvariceal upper gastrointestinal bleeding.
    • Endoscopic variceal ligation is superior to sclerotherapy for variceal
    bleeding. May attempt injection of N-butyl-2-cyanoacrylate for gastric
    varices.
    • Endoscopic variceal ligation in combination with pharmacotherapy is
    superior to ligation alone
    UPPER GI HEMORRHAGE Return to CPG

    Forrest Classification and Risk of Re-Bleeding


    Grade Endoscopic Picture Risk of Re-bleed
    I: Active Bleeding
    Ia Spurting 90%
    Ib Oozing without visible vessel 10%
    II: Signs of Recent Bleed
    IIa Non-bleeding visible vessel 50%
    IIb Adherent clot 25-30%
    IIc Hematin covered flat spot 7-10%
    III: No Bleed Clean based ulcer 3-5%

    Adapted from Moffat B, et al. UGI Hemorrhage in The Surgical Critical Care Handbook (Chap. 28)
    Katschinski B, Logan R, Davies J, et al. 1994. Dig Dis Sci
    UPPER GI HEMORRHAGE Return to CPG

    Endoscopic Findings
    Stigmata of recent hemorrhage and average rates (with ranges) of further bleeding,
    surgery, and mortality in prospective trials without endoscopic therapy
    Further Bleeding Surgery for Bleeding Mortality
    Stigmata
    (N=2,994) (N=1,499) (N=1,387)
    Active Bleeding 55% (17-100%) 35% (20-69%) 11% (0-23%)

    Non-bleeding 43% (0-81%) 34% (0-56%) 11% (0-21%)


    Visible Vessel
    Adherent Clot 22% (14-36%) 10% (5-12%) 7% (0-10%)
    Flat Pigmented 10% (0-13%) 6% (0-10%) 3% (0-10%)
    Spot
    Clean Ulcer Base 5% (0-10%) 0.5% (0-3%) 2% (0-3%)

    Laine L, Jensen DM. 2012. Am J Gastroenterol


    UPPER GI HEMORRHAGE Return to CPG

    Post-Endoscopy Management
    Non-Variceal Bleed
    • Should be treated with IV PPI bolus (Pantoprazole 80mg) followed by
    continuous infusion (8mg/h for 72 hours).

    Variceal Bleed
    • Should receive octreotide 50ug IV bolus followed by infusion (50ug/h)
    for 3 – 5 days.
    • Should continue prophylactic antibiotics.
    • Balloon tamponade can be used as a temporizing measure
    o Tracheal intubation is required.
    o Must confirm balloon is in the proper place before inflating in order
    to avoid esophageal rupture.
    • Consider transjugular intrahepatic portosystemic shunt (TIPS) if bleeding
    not controlled endoscopically.
    UPPER GI HEMORRHAGE Return to CPG

    Article providing instructions for balloon tamponade insertion

    Blakemore Tube Linton Tube Linton Tube


    inflated in stomach
    Images courtesy of Dr. P Engels
    UPPER GI HEMORRHAGE Return to CPG

    Endoscopic Failure or Re-Bleed


    • Routine repeat endoscopy is not recommended.
    • Repeat endoscopy should be performed if evidence of recurrent
    bleeding.
    • Surgery should be offered when nonvariceal bleeding cannot be
    controlled after endoscopy (maximum 2 endoscopies).
    • Interventional radiology may be offered if readily available and if patient
    has “hostile” abdomen or significant medical comorbidities.
    UPPER GI HEMORRHAGE Return to CPG

    Surgery for Non-Variceal Bleed


    • Surgical tenants for upper gastrointestinal hemorrhage now suggest
    performing “minimal” surgery to confirm diagnosis and control the
    bleeding (suture ligation or wedge resection).
    • Preferred operative approach depends on location of the bleed.
    • “Definitive” ulcer surgery is rarely done in emergent settings given
    medical treatment of H. pylori and acid suppression with proton pump
    inhibitors.
    • Anatomic resection is generally reserved for bleeding neoplasms;
    however the physiologic status of the patient will determine the extent
    of the operation in such instances, and again “minimal” surgical
    interventions may be required
    UPPER GI HEMORRHAGE Return to CPG

    Surgery for Duodenal Ulcer Bleed


    • After mobilization, the duodenum is opened
    longitudinally (not necessary to go through the
    pylorus as vagotomy is rarely performed).
    • Non absorbable suture on stout needle is used
    to ligate gastroduodenal artery (e.g. 2-0
    Ethibond on MO-6 needle) with figure of eights
    in classic 2 or 3 point fixation.
    • Duodenum can be closed in single layer (not
    necessary to close transversely)

    Cameron JL, Cameron AM. The Management of Duodenal Ulcer. 2008. Current Surgical Therapy
    UPPER GI HEMORRHAGE Return to CPG

    Surgery for Gastric Ulcer Bleed


    • Best treated with wedge resection due to potential malignancy (5%).
    • Proximal lesser curve or gastroesophageal (GE) junction ulcers are more
    problematic as wedge resection may not be feasible – compromise GE
    junction and higher leak rate.
    • They may be controlled with direct suture ligation after gastrotomy or
    Pauchet or Csendes procedure.

    Figures from Townsend CM, et al. 2007. Sabiston Textbook of Surgery. Fig. 47-16.
    UPPER GI HEMORRHAGE Return to CPG

    Summary
    • Hemodynamically unstable patients have higher likelihood of operative
    intervention.
    • Management of upper gastrointestinal bleeding requires a dedicated
    multidisciplinary approach.
    • Vast majority of bleeds can be controlled with endoscopy and surgery
    has shifted from “definitive” ulcer surgery to direct control of bleed.
    UPPER GI HEMORRHAGE Return to CPG

    Additional Resources
    International Practice Guidelines
    1. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J
    Gastroenterol 2012;107:345-60.
    2. Gralnek IM, Dumonceau JM, Kuipers EJ, et al. Diagnosis and management of
    nonvariceal upper gastrointestinal hemorrhage: European Society of
    Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015;47(10):a1-46
    3. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus
    recommendations on the management of patients with nonvariceal upper
    gastrointestinal bleeding. Ann Intern Med 2010;152:101-13.
    4. National Institute for Health and Clinical Excellence. Acute upper gastrointestinal
    bleeding: management. London: National Clinical Guideline Centre at the Royal
    College of Physicians, 2012.
    5. Garcia-Tsao G, Sanyal AJ, Grace ND et al. Prevention and management of
    gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J
    Gastroenterol 2007;102:2086-2102.

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