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16 Diaphragmatic Emergencies 13 7
Fig. 16.3. Axial CT scan through the lower thorax. (a) Air fluid level in a distended
stomach with shift of the heart to the right. The “bubble” on the right represents the
gastric antrum. Note the nasogastric tube in the distal esophagus to the right of the aorta.
(b) A lower cut with the spleen visible on the left. The left bubble represents the gastric
fundus. Note the “transition line” between the two bubbles representing the site of the
volvulus
Management
Although emergency room staff tend initially to eyeball these patients and
label them as suffering from “respiratory failure” or myocardial infarction, a
prompt chest X-ray will suggest the diagnosis and promote further aggressive
imaging studies. The presence of the stomach (or other viscera) in the chest in
this clinical scenario is a dire surgical emergency because of the unpredictability
138 Ulrich Schoeffel · Moshe Schein
of the situation; the patient may appear well, but the stomach may be rapidly
becoming necrotic. On the other hand, of course, an asymptomatic upside-down
stomach may coexist with other intrathoracic emergencies.
The treatment of acute gastric volvulus is surgical, consisting of a laparotomy, reduction of the volvulus, and assessment of gastric viability. The vast
majority of acute diaphragmatic hernias can be reduced through the abdomen
and very rarely is there a need to add a thoracotomy. Reduction of the herniated
viscera may be aided by two maneuvers: inserting a wide tube through the dia-
phragmatic defect abolishes the negative, “sucking” thoracic pressure, and a
nasogastric tube may be manipulated into the distended stomach to reduce its
size. When the latter is not successful, a decompressive gastrotomy is necessary
before the stomach can be reduced into the abdomen. This should be performed
carefully in order not to contaminate the thoracic cavity—an event that often
leads to postoperative empyema.
After the hernia is reduced, the hernial sac is excised, and the diaphragmatic
defect is closed with interrupted sutures. A very large defect may need to be patched
with a synthetic prosthesis, although this is not advised in the presence of contamination. Finally, some experts would recommend a tube gastrostomy—well
sutured to the anterior abdominal wall—to decompress the stomach and prevent
recurrence of the volvulus. Others have recommended gastropexy—suturing of
the stomach to the abdominal wall or even to a window created in the avascular
area of the transverse mesocolon. The addition of an antireflux procedure, such as
fundoplication, is controversial—and most probably inadvisable—in such emergency situations when it is unknown whether the patient has also a sliding hernia
and gastroesophageal reflux.
When the stomach is found to be nonviable, gangrenous portions are
resected by partial or total gastrectomy as required. In the moribund patient who
needs total gastrectomy, it may be safer to postpone the reconstruction: insert a
tube to drain the distal esophagus, close the duodenal stump, and place a tube
jejunostomy distal to the level of the eventual planned entero-entero component
of the Roux-en-Y loop jejunoesophagostomy, which will be performed once the
patient is stabilized and ready for such a reintervention.
In selected hemodynamically stable patients, laparoscopic reduction and
detorsion of the stomach followed by endoscopic gastropexy or fundoplication
have been reported possible. The finding of gastric necrosis would call for immediate conversion to an open approach.
Upper Gastrointestinal
Hemorrhage (and Portal
Hypertension)
Moshe Schein
“If anyone should consider removing half of my good stomach to cure a small ulcer
in my duodenum, I would run faster than he.” (Charles H. Mayo, 1861–1939)
“About gastrectomy for duodenal ulcer: in this operation … a segment of an essen-
tially normal stomach is removed to treat the disease next door in the duodenum. It
is like taking out the engine to decrease noise in the gear box.” (Francis D. Moore,
1913 –2 001)
During my residency in the 1980s, not a week passed without a few operations for bleeding duodenal (DU) or gastric (GU) ulcers. Emergency gastrectomies, antrectomies, truncal vagotomies, and highly selective vagotomies were
our daily bread and butter. But, gradually things started to change. First appeared the H2 antagonists, followed by proton pump inhibitors (PPIs), and then
anti-Helicobacter therapy. In addition, novel methods of achieving transendoscopic hemostasis of bleeding ulcers emerged. As a result, at least where we practice, operations for upper gastrointestinal hemorrhage (UGI-H) have become a
rarity, and our approach to them has been modified. However, if you work somewhere in the so-called developing world, where modern antiulcer medications
are not freely available, you may be exposed still to the old pattern of peptic ulcer
disease and the traditional methods of dealing with it.
In all likelihood, you are becoming less and less familiar and skilled in the
operative management of UGI-H. Therefore, you need to listen to us—☺ …
17
The Problem
Upper gastrointestinal hemorrhage implies a source of bleeding proximal
to the liga ment of Treitz . Although textbooks list multiple causes, the vast major-
ity of patients bleed from a chronic DU or GU, complications of portal hypertension (esophageal varices or hypertensive gastropathy; acute complications of
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_17, © Springer-Verlag Berlin Heidelberg 2010
139
140 Moshe Schein
portal hypertension), or acute gastric mucosal lesions (e.g., stress ulcers, erosive
gastritis, and other terms that mean more or less the same). The last are usually
due to ingestion of analgesics or alcohol (“aspirin for the hangover”). With the
routine use of antiulcer prophylaxis in hospitalized “stressed” patients, significant UGI-H from mucosal lesions is now rare. In fact, hemorrhage in stressed
patients often originates from reactivated chronic peptic ulcers. Other potential
sources of bleeding are the Mallory-Weiss tears in the mucosa at the gastroesoph-
ageal junction, usually caused by severe retching, coughing, or vomiting, and the
Dieulafoy lesion, a manifestation of a gastric submucosal vascular abnormality.
The exact mixture of etiologies in your hospital depends on local social
habits and the sort of population with which you work.
Presentation
Patients present either with hematemesis (vomiting fresh blood), melenemesis
(vomiting altered “coffee-ground” material), or melena (passage of black stool per
rectum). Hematochezia (passage of fresh or altered nonblack blood per rectum) usu-
ally originates from a source below the ligament of Treitz. Nevertheless, with massive
UGI-H and rapid intestinal transit, unaltered blood may appear in the rectum.
Remember:
Melena is black, sticky, and very smelly
Maroon feces are not melena
Red feces are not UGI bleeding
Black blood per rectum always means UGI bleeding
Fresh, red blood per rectum in a hemodynamically stable patient means
that the source is not in the UGI tract
Any type of blood—fresh or old, vomited, or retrieved through the
nasogastric tube—means that the source is in the UGI tract
You do not need panendoscopy to diagnose UGI-H—contrary to the gastroenterologists’ credo. A finger, a nasogastric tube, and a pair of eyes are as good.
Key Issue: Is the Hemorrhage “Serious”?
Whether the hemorrhage is “serious” is a key issue because the seriousness of
hemorrhage determines your diagnostic-therapeutic steps and the patient’s outcome. In general, the larger the bleeding vessel, the more serious the hemorrhage.
17 Upper Gastrointestinal Hemorrhage (and Portal Hypertension) 141
The more serious the hemorrhage, the less likely it is to stop without an intervention, and the more likely it is to recur after it has stopped. As with almost any acute
medical or surgical condition, the affected patients can be classified into three
groups: the obviously serious and obviously not serious at both extremes and the
potentially serious group in the middle. This intermediate group is always the most
problematic in terms of diagnosis and selection of therapy but, at the same time,
includes those patients for whom your correct management can improve outcome.
Whatever the condition, the mildly ill patient should do well, and the very sick one
may die in spite your efforts. It is the moderately ill who will most benefit from
your ministrations.
Stratification
Massive bleeding from a large vessel requires your immediate attention and
intervention. A small ooze from a tiny vessel is usually self-limiting and of minor
significance at least for the moment; you can investigate it electively. For most
patients, however, the emergence of any quantity of blood from the mouth, anus,
or any bodily orifice is alarming.
When Should You Be Alarmed?
The literature contains various formulas, usually based on hemodynamic
parameters and the volume of blood transfusions required, to distinguish between
“massive” versus “nonmassive” UGI-H. We suggest, however, that you use your common sense and consider the following clinical paradigm for when to be alarmed:
Is the vomited blood (or the aspirate in the nasogastric tube) fresh or coffee
ground material?
Are the rectal contents fresh, juicy melena or old dry melena?
Is, or was, the patient hemodynamically compromised?
Is there laboratory evidence (hemoglobin/hematocrit) of severe bleeding?
Is the patient over 60 years of age? Bleeding in elderly patients merits
greater concern because they are less likely to withstand a prolonged
hemorrhage. (We find the APACHE II [Acute Physiological and Chronic
Health Evaluation II] scoring system discussed in > Chap. 6 useful in this
situation as it reflects the acute physiological compromise inflicted on the
patient by the bleeding, while taking account of age and comorbitidies.)
These considerations should place your patients somewhere on the large
spectrum of UGI-H seriousness. At one extreme, the patient presenting in shock,
with fresh blood pouring from the stomach, belongs to the serious group (group I);
142 Moshe Schein
at the other, the stable patient, with a little coffee ground material and old, hard
melena is definitively not serious (group III). Many patients, however, belong
to the potentially serious group (group II); the problem here is to distinguish
between those who continue to ooze, or will rebleed, and those who have stopped
bleeding and whose chance of rebleeding is low. This distinction requires active
observation and endoscopy.
Approach
In many parts of the world, patients presenting with UGI-H are initially
seen by internists or gastroenterologists. We surgeons are usually called to take
part in the management only when these specialists believe that they cannot stop
the bleeding without our help—and this may be too late—which means that they
may call you “to operate” when the patient is already unsalvageable. Yes, even in
today’s era of fancy endoscopic hemostasis and intensive care units (ICUs), patients can die from bleeding ulcers—I recall a young man admitted to a teaching
New York hospital and undergoing two attempts at endoscopic control of his
bleeding DU. He continued bleeding in the ICU; when I was called, he had bled
out. I operated but too late—his life was lost because a simple hemostatic stitch
to block the pumping gastroduodenal artery was not inserted in time. Thus, we
have to know better how to manage these patients and encourage early referral to
the surgeon.
Check vital signs. Aggressive management of hypovolemic shock is the first prior ity. Do not overtransfuse as there is evidence that excessive blood product admin-
istration exacerbates bleeding and results in a higher incidence of rebleeding.
With resuscitation under way, take a history. Previous peptic ulceration?
Dyspepsia? Antiulcer medications? (Remember, bleeding patients do not have pain
because blood is alkaline and serves as an antacid.) Recent consumption of analgesics or
alcohol? Severe vomiting or retching (Mallory-Weiss)? Chronic liver disease or varices?
Nosebleed (swallowed blood)? Coagulopathy? Amount of blood vomited or passed per
rectum (extremely inaccurate)? Full medical history (operative risk factors)?
Pass a large-bore nasogastric tube. Flush the stomach with 50 ml water, and
aspirate; fresh blood indicates active or a very recent hemorrhage; coffee ground
material denotes recent bleeding that has stopped, while clean aspirate or bile
means no recent hemorrhage. Note: very rarely, a bleeding DU is associated with
pyloric spasm with no blood refluxing into the stomach; bile-stained aspirate
excludes such a possibility.
Perform a rectal examination. Fresh blood or juicy soft melena indi-
cates active or very recent bleeding, while dry and solid melena signifies a
nonrecent UGI-H (>Fi g . 17.1).
17 Upper Gastrointestinal Hemorrhage (and Portal Hypertension) 143
Fig. 17.1. “This is a ‘serious’ UGI hemorrhage”
How to Proceed?
Now, with all this information in mind, you can classify the patients into
one of the three groups (>Table 17.1).
The “nonserious bleeder” (group III). These patients have suffered a minor
hemorrhage, which has stopped. Do not rush to endoscopy in the middle of the
Table 17.1. Stratification and management of patients with upper gastrointestinal hemorrhage (UGI-H)
Group I,
serious
Vom it i ng Fresh blood Coffee ground or
Per rectum Fresh melena/blood Fresh melena Old melena
Hemodynamically Compromised Stable Stable
Hemoglobin/
hematocrit
Approach Endoscopy now Endoscopy soon Endoscopy tomorrow
Prognosis Requires hemostasis Va ria bl e Self-limiting
<9/27 >9/27
Group II,
potentially serious
fresh
Group III,
not serious
Nothing/coffee
ground
144 Moshe Schein
night. Semi-elective investigation suffices and is more accurate and safer. Note
that a very low hematocrit/hemoglobin in patients belonging to this group results
from a chronic or intermittent ooze. The very anemic patient will tolerate endoscopy better after his or general condition is improved. These patients do not
require an emergency operation, and therefore they are not discussed further.
The serious bleeders (group I). In a minority of patients belonging to this
group, fresh blood is pouring torrentially from the stomach; they are virtually
exsanguinating. You have to move fast. Esophageal or gastric varices often bleed
this way—like an open tap. In such cases, a previous history of portal hypertension
or clinical stigmata of chronic liver disease often coexist, suggesting the diagnosis.
Remember: you do not want to operate on varices (see the end of this chapter).
In any event, you should transfer the exsanguinating patient to a critical
care facility or the operating room. Intubate and sedate him or her to facilitate
gastric lavage and subsequent endoscopy and, most importantly, to reduce the
risk of aspiration of the gastric contents in the shocked, obtunded, bleeding
p a t i e n t . You should attempt endoscopy because, even if gastroduodenal visualiza-
tion is totally obscured by blood, fresh bleeding from esophageal varices (usually
at 40 cm from the teeth, at the gastroesophageal junction) always can be detected,
mandating a subsequent nonoperative approach. In the absence of varices, proceed to surgery. The serious patients who are not exsanguinating should undergo
an emergency endoscopy (as discussed for group II individuals).
The potentially serious bleeder (group II). Perform an emergency endoscopy.
Emergency Endoscopy for UGI-H
Emergency endoscopy for UGI-H should be done only after you have resuscitated the patient and are in a controlled environment. Endoscopy induces hypoxemia
and vagal stimulation; we have seen it cause cardiac arrest in unstable and poorly
oxygenated patients. (In addition, closed cardiac massage on 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 be present at the endoscopy to visualize the findings first hand. Do
not entirely trust the gastroenterologist, who will be going home soon, leaving you
with the patient and any problems resulting from a poorly identified bleeding site.
To improve the diagnostic yield, the stomach should be prepared for endoscopy. Pass the largest nasogastric tube you can find and flush the stomach rapidly
and repeatedly, aspirating as many clots as possible. A common ritual is to use
ice-cold saline (with or without a vasoconstricting agent) for this purpose. None
of these methods has been proven to be therapeutic. Tap water is just as good and
much cheaper and does not aggravate hypothermia.
17 Upper Gastrointestinal Hemorrhage (and Portal Hypertension) 145
Table 17.2. Suggested classification of UGI-H
No evidence of recent bleeding Evidence of recent bleeding Active bleeding
Clean base Flat spot
Adherent clot
Visible vessel
Oozing
Spurting
At endoscopy, you attempt to visualize the source of bleeding, which may
be esophageal (varices, Mallory-Weiss, esophagitis); gastric (chronic GU or
superficial lesions); duodenal (DU); solitary (chronic ulcer); or multiple (erosive
gastritis). Look also for the following prognostic stigmata:
Active bleeding from lesion
A “visible vessel” standing up in the ulcer’s base, indicating that the bleeding orig-
inated from a large vessel and that there is a high chance of further hemorrhage
A clot adherent to the ulcer’s base, signifying a recent hemorrhage
You may like to classify the findings as presented in > Table 17.2.
Endoscopic Management
Having visualized the lesion you should now treat it endoscopically to achieve
hemostasis and to reduce the risk of further hemorrhage. In broad terms, endoscopic
therapy has a better chance of success in shallow lesions, which contain small vessels.
However, you should also attempt endoscopic hemostasis in deeper, large-vessel-containing lesions, with the aim of achieving at least temporary cessation of bleeding. This
will permit a safer, elective, definitive operation to be performed in a better-prepared
patient. The specific method of endoscopic hemostasis, be it a “hot” probe or injection
with adrenaline or a sclerosant, depends on local skills and facilities. As in most places
it will be performed by the gastroenterologists, the technique is not discussed here.
Postendoscopy Decision Making
At the end of endoscopy, you are left with the following categories of patients:
Actively bleeding: failed endoscopic hemostasis. The source is usually a
chronic ulcer and emergency operation is indicated.
Bleeding (apparently) stopped: chronic ulcer with a “visible vessel” or
adherent clot visualized. The chances of further hemorrhage, usually
within 48–72 hrs, are substantial. Treat conservatively but observe closely.
Bleeding stopped: acute shallow lesion or chronic ulcer without the afore-
mentioned stigmata. In these patients, further hemorrhage is unlikely;
treat conservatively and relax.
146 Moshe Schein
Conservative Treatment
The mainstay of conservative treatment comprises completion and mainte-
nance of resuscitative measures and observation for further hemorrhage. In earlier
editions of this book, we decried the use of PPIs as a useless intervention in acute
UGI-H. We have changed our opinion. (“When the facts change, I change my mind!
What do you do, sir?” John Maynard Keynes) There is now good evidence that
administration of high-dose PPIs in patients with peptic ulceration reduces the
incidence of rebleeding and the need for surgery following endoscopic hemostasis.
Obviously, correct coagulopathies if present. All you need to do is to sustain the
patient’s organ systems and watch for rebleeding, which usually occurs within
48–72 hrs and can be massive and lethal. Careful monitoring of vital signs, obser-
vation of the number and character of melena stools, and serial hematocrit measurements will detect episodes of further hemorrhage. A nasogastric tube on
suction is often advocated to provide early warning. In our experience, however, it
is often blocked by clots, is of great discomfort to the patient, and therefore worse
than useless. If, nonetheless, you choose to use it, flush it frequently.
Indications for Operation
I do not suggest that you use cookbook recipes or formulas as they are of
little help in the individual patient. Instead, use clinical judgment. That the exsanguinating patient and the one who continues to bleed after endoscopic hemostasis
fails need an emergency operation is clear and has been discussed. Regarding
those in whom the hemorrhage has stopped, with or without endoscopic hemostasis, the main indication for operation is recurrent hemorrhage. Factors that may or
may not modify your decision to operate include the magnitude of recurrent hemorrhage, its source, and the age and general condition of the patient.
In general terms, recurrent hemorrhage is an ominous sign, meaning that
bleeding will continue or, if stopped again, may well recur.
If hemodynamically significant or originating from a chronic ulcer, you
have to operate.
If rebleeding seems of mild or moderate magnitude and stems from a
superficial lesion, you may elect to continue conservative treatment or
retreat endoscopically.
Gastroenterologists are now keen to repeat endoscopic therapy in rebleeding patients and even to do so a few times. Commonly, those patients “belong” to
them, and you cannot interfere but watch them carefully and be ready to act.
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