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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_725_Библиотеки_им_академика_М_И_Перельмана
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attentionandintervention.Asmalloozefromatinyvesselisusuallyselflimiting and of minor significance at least for the moment; you can
investigate it electively. For most patients, however, the emergence of
anyquantityofbloodfromanybodilyorificeisalarming!
The literature contains various formulas, usually based on
hemodynamicparametersandthevolumeofbloodtransfusionrequired,
to distinguish between ‘massive’ versus ‘non-massive’ UGIB. We
suggest,however, that you use your common sense and consider
theclinicalparadigmconsistingofthefollowing:
•
Isthevomitedblood(ortheaspirateinthenasogastrictube)fresh
or‘coffeeground’?
•
Aretherectalcontentsfresh,juicymelena,orolddrymelena?
•
Is,orwas,thepatienthemodynamicallycompromised?
•
Isthepatientrequiringabloodtransfusiontomaintainstability?
•
Is there laboratory evidence of severe bleeding (hemoglobin/
hematocrit)?
•
Isthepatientover60 years of age?Bleeding in elderlypatients
merits greater concern because they areless likely to withstanda
prolongedhemorrhage.
•
What is thepatient’s overallphysiological status? We findthe
APACHEII1scoringsystem(
Chapter6
)usefulinthissituationas
itreflectstheacutephysiologicalcompromiseinflictedonthepatient
bythebleeding,whiletakingintoaccountageandcomorbidity.
What is true in acute surgery in general istrue forUGIB: thevolume of bleeding, the
degree of physiological compromise, the number of units transfused — all correlate
withmorbidity,theriskofrebleeding,theneedforsurgeryandmortalityrates.
Stratification
These considerations should place your patients somewhere on the
largespectrumofUGIB‘seriousness’:
•
At one extreme, the patient presenting in shock, with fresh blood
pouringfromhisstomach,belongstotheseriousgroup.
•
At the other,the stablepatient, with alittle coffeeground and old,
hardmelenaisdefinitivelynotserious.
•
Manypatients,however, belong to the potentially seriousgroup;
theproblemhere is to distinguish between thosewho continue
toooze,orwillrebleed,andthosewhohavestoppedbleeding
andwhosechanceofrebleedingislow.Thisdistinctionrequires
activeobservationandendoscopy.
Approach
As introduced above, in manyparts of the world, patientspresenting
withUGIBare initially seen by internistsand/orgastroenterologists. We
surgeons are usually called to takepart inthe managementonly when
thesespecialistsbelievethattheycannotstopthebleedingwithoutour
help—andthismaybetoolate—whichmeansthattheymaycallyou
‘tooperate’whenthepatientisalreadyunsalvageable.Ohyes,evenin
today’s era of fancy endoscopic hemostasis and intensive care
units,patients candiefrom bleedingulcers—I recall a young man
admittedtoaNewYorkteachinghospitalandundergoingtwoattemptsat
endoscopic control of his bleeding DU. He continued rebleeding in the
ICU;whenIwascalledhehadbledout.Ioperatedbuttoolate—hislife
waslost becauseasimplehemostaticstitchtoblock thepumping
gastroduodenal artery wasnot inserted in time. Wehave to know
better how to manage these patients and encourage the early
involvementofsurgeonsintheirmanagement.
Whattodoifyouaretakingcareofthebleedingpatient?
Figure17.1.“Thisisa‘serious’UGIhemorrhage.”
•
Check vital signs. Aggressive management of hypovolemic
shockis the first priority.Do not over-transfuse(!) as there is
evidence that excessive blood product administration exacerbates
bleedingandresultsinahigherincidenceofrebleeding.
•
With resuscitation underway, take a history. Previous peptic
ulceration? Dyspepsia? Anti-ulcer medications? (Remember,
bleeding patients do not have pain because blood is alkaline and
serves as an anti-acid.) Recent consumption of analgesics or
alcohol?Severevomitingorretching(Mallory-Weiss)?Chronicliver
disease and/or varices? Nose bleed (swallowed blood)?
Coagulopathy? Amount of blood vomited or passed per rectum
(extremelyinaccurate)?Fullmedicalhistory(operativeriskfactors)?
•
Passalarge-borenasogastrictube,flush thestomach with50ml
ofwater,and aspirate:freshbloodindicatesactiveoraveryrecent
hemorrhage; coffee ground denotes recent bleeding which has
stopped;cleanaspirateorbilemeansnorecenthemorrhage.Note:
veryrarely,ableedingDUisassociatedwithpyloricspasmwithno
blood refluxing into the stomach; a bile-stained aspirate excludes
thispossibility.
•
Perform a rectal examination: fresh blood or juicy soft melena
indicatesactiveorveryrecentbleeding,whiledryandsolidmelena
signifiesanon-recentUGIB( Figure17.1).
Howtoproceed?
Now, with all the above information in mind you can classify the
patientsintooneofthethreegroupsmentionedabove( Table17.1).
The‘non-seriousbleeders’
Thesepatientshavesufferedaminorhemorrhage,whichhasstopped.
Donotrushtoendoscopyinthemiddleofthenight. Semi-elective
investigationsuffices,andismoreaccurateandsafer.Notethatavery
low hematocrit/hemoglobin in patients belonging to this group
resultsfrom a chronic orintermittentooze.The very anemic patient
will tolerate endoscopy better after his general condition is improved.
Thesepatientsdonotrequireanemergencyoperationandthereforethey
won’tbediscussedfurther.
The‘seriousbleeders’
In a minorityof patients belongingto this group,fresh blood is
pouring torrentially from the stomach; they are virtually
exsanguinating!You have to movefast.Esophageal or gastric varices
oftenbleedthisway—likeanopentap.Insuchcasesaprevioushistory
of portal hypertension orclinical stigmata of chronicliver disease often
coexist, suggesting the diagnosis. Remember — you do not want to
operateonvarices(see Chapter25).
Inanyevent,youshouldtransfertheexsanguinatingpatienttoacritical
care facility or the operating room. Intubate and sedate him/her to
facilitate gastric lavage and subsequent endoscopy, and, most
importantly,toreducetheriskofaspirationofthegastriccontents
in the shocked, obtunded, bleeding patient. You should attempt
endoscopy because, even if gastroduodenal visualization is totally
obscured by blood, fresh bleeding from esophageal varices (usually at
40cm from the teeth, at the gastroesophageal junction) can always be
detected, mandating a subsequent non-operative approach. In the
absence of varices you should MYA 2 rapidly: to surgery or
angiography.
We use a large-lumen irrigation endoscope that is capable of suctioning clots rapidly and
irrigatingwithhighforce.Ari
Theseriouspatientswhoarenotexsanguinatingshouldundergo
an emergency endoscopy, as should the ‘potentially serious’
bleeders.
EmergencyendoscopyforUGIB
Thisshouldbedoneonlyafteryouhaveresuscitatedthepatient
and are ina controlled environment. Endoscopy induces hypoxemia
andvagal stimulation; wehave seen itcausecardiac arrest inunstable
andpoorlyoxygenatedpatients(inaddition,closedcardiacmassageon
a patient with a stomach ballooned with blood may lead to gastric
rupture). Ideally, you — the surgeon — should be the one who
performs the procedure.Unfortunately, because of political and fiscal
considerations, in many hospitals you are denied this access to
endoscopy. If this is the case — at least try to be present at the
endoscopy to visualize the findings first hand. Do not entirely trust the
gastroenterologist;he’llbegoinghomesoon,leavingyouwiththepatient
andanyproblemsresultingfromapoorlyidentifiedbleedingsite.
Toimprovethediagnosticyieldthestomachshouldbeprepared
forendoscopy.Passthelargestnasogastrictubeyoucanfindandflush
thestomachrapidlyandrepeatedly,aspiratingasmanyclotsaspossible.
A common ritual is to use ice-cold saline (with or without a
vasoconstrictingagent) for thispurpose.These methods havenotbeen
proventobetherapeutic. Tap wateris justas good,muchcheaper,and
doesnotaggravatehypothermiawhichmayimpedeclotting.
At endoscopy,attempt to visualize the potential sources of bleeding,
mentionedabove.Lookalsoforthefollowingprognosticstigmata:
•
Activebleedingfromlesion.
•
A ‘visible vessel’ in the ulcer’s base, indicating that the bleeding
originated from a large vessel and that there is a high chance of
furtherhemorrhage.
•
Aclotadherenttotheulcer’sbase,signifyingarecenthemorrhage.
You may like to classify the findings according to the Forrest
classificationaspresentedin Table17.2.
Endoscopicmanagement
Havingvisualized thelesion youshould nowtreatitendoscopicallyin
order to achieve hemostasis and to reduce the risk of further
hemorrhage.Inbroadterms,endoscopictherapyhasabetterchanceof
success in shallow lesions, which contain small vessels. However, you
should also attempt endoscopic hemostasis in deeper, large vesselcontaininglesions,withtheaimofachievingatleasttemporarycessation
ofbleeding.Thiswillpermitasafer,semi-elective,definitiveoperationto
be performed in a better-prepared patient. The specific method of
endoscopichemostasis,beita‘hot’probe,clips,rubberbands,injection
with adrenaline or a sclerosant, or even glue (frankly, it could be that
eveninjectionofCocaColamaybeeffectiveinstoppingbleeding,which
intheolddayswouldstopspontaneously…),dependsonlocalskillsand
facilities. In fact, some experts claim that single-mode endoscopic
treatment has no role and advocate ‘triple endoRx’. Since it will be
performedinmostplaces bythegastroenterologistswewillnotconcern
ourselvesherewithtechnique.
Nevertheless, our standardapproach is adrenalin plus fibrin glue for actively bleeding ulcers.
With a Dieulafoy’s lesion we use clips (plus angioembolization as needed) and with gastric
fundusvaricesweusespecialglue.Ari
Post-endoscopydecision-making
Attheendof endoscopy you, or the ‘other endoscopist’, are left with
thefollowingcategoriesofpatients:
•
Activelybleeding:failedendoscopichemostasis!The source is
usuallyachroniculcerandemergencyoperationisindicated.But
if you have a readily available and skilled angiographer, you may
wishtoconsulthim…
•
Bleeding (apparently) stopped: e.g. chronic ulcer with a ‘visible
vessel’ or adherent clot visualized. The chances of further
hemorrhage, usually within 48-72hours, are substantial.Treat
conservativelybut observeclosely —youmay besittingon atime
bomb!
Our policy in the high-risk group — if the bleeding apparently has stopped — is to repeat
gastroscopythenextday.WeFinnsdonotliketositonbombs.Ari
•
Bleeding stopped: e.g. acute shallow lesion or chronic ulcer
without the aforementioned stigmata. In these patients further
hemorrhageisunlikely;treatconservativelyandrelax.
Conservativetreatment
The mainstay of conservative treatment comprises completion
and maintenance of resuscitative measures, and observation for
furtherhemorrhage.Inearliereditionsofthisbookwe decriedthe use
ofprotonpumpinhibitors(PPIs)asauselessinterventioninacuteUGIB.
We have changed our opinion. (“When the facts change, I change my
mind.Whatdoyoudo,sir?”JohnMaynardKeynes.)Thereisnowgood
evidencethattheadministrationofhigh-dosePPIsinpatientswithpeptic
ulcerationreducestheincidenceof rebleedingand theneedforsurgery
following endoscopic haemostasis. Obviously, correct coagulopathies if
present.Allyouneedtodoistosustainthepatient’sorgansystems,
andwatchforrebleeding,whichusuallyoccurs within48-72hours
and can be massive and lethal. Careful monitoring of vital signs,
observation of the number and character of melena stools and
serial hematocrit measurements will detect episodes of further
hemorrhage.Anasogastrictubeonsuctionisoftenadvocatedtoprovide
earlywarning.Inourexperience,however,itisoftenblockedbyclots,is
ofgreatdiscomforttothepatientandisthereforeworsethanuseless.If,
nonetheless,youchoosetouseit,flushitfrequently.
Themanagementofrebleeding
Thepatienthasbledagain!Whatnow?Re-endoscopictreatment?
Rush to the operating room? Transferto the arteriography suite?
Well,italldepends…
Wedonotsuggestthatyouusecookbookrecipesorformulas,asthey
areoflittlehelpinthe individual patient. Instead, use clinical judgment.
That the exsanguinating patient, and the one who continues to bleed
afterendoscopichemostasisfails,needanemergencyoperationisclear
and has been discussed above. But what to do with recurrent
hemorrhage? Factors that may or may not modify your decision to
operateinclude themagnitudeof recurrenthemorrhage, its source,and
theageandgeneralconditionofthepatient.
In general terms, recurrent hemorrhage is an ominous sign,
meaningthatbleedingwillcontinueor,ifstoppedagain,maywellrecur!
Soouradviceis:
•
Ifhemodynamicallysignificantyouhavetooperate!
•
If rebleeding seems of mild or moderate magnitude you may
electtocontinueconservativetreatmentorretreatendoscopically.
•
The source ofthe bleeding may influence your decisions: e.g. a
chronic,giantulcermaytiltthescaletowardssurgery;asuperficial,
acutesourcemayguideyoutoavoidanoperation.
Gastroenterologists are nowadays very keen to repeat
endoscopictherapyinrebleedingpatients—allofthem, eventhose
whosquirtitoutinapulsatilestream—andeventodosoafewtimes.
Commonly,thosepatients‘belong’tothemandyoucannotinterfere,but
youshouldwatchthem‘fromtheside’andbereadytoact.Afterrepeated
endoscopicmaneuverssometimesnotmuchwillbeleftofthefirstpartof
theduodenumwhenyoueventuallyoperate.
Well,let’snotexaggerate…Danny
Acolleagueofminesaidthis:
Why are gastroenterologists more imaginative and
courageous than we surgeons in employing new and
bizarreinvasivetherapeuticmodalities?Becausetheyhave
somebody(us)tobailthemout!
EliMavor
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