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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_907_Библиотеки_им_академика_М_И_Перельмана
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more likely to have arterial-venous malformations or
bleeding from gastritis from platelet dysfunction. He could
also have esophageal disease such as a Mallory-Weiss
tear from vomiting and, less likely, variceal hemorrhage
since he provides no history of cirrhosis. But with his history
of hemodialysis and renal failure, he does have a higher
risk of hepatitis. Less likely in this scenario, given the acute
onset, would be upper gastrointestinal tract neoplasms
such as esophageal, gastric, or duodenal tumors.
Workup
At this point, if a nasogastric tube were not in place, one
should be placed for gastric lavage and evacuation of the
stomach. Given his history of hematemesis, an
esophagogastroduodenoscopy (EGD) would be the next
diagnostic and potentially therapeutic procedure of choice.
If there is any concern over perforation in addition to
bleeding, an abdominal radiograph should be performed
prior to EGD. Laboratory tests that should be drawn to
establish baseline values would be a complete CBC with
platelets, PT with INR, PTT, type and screen, a
comprehensive metabolic panel to assess for electrolyte
abnormalities. An arterial blood gas should be drawn to
evaluate for metabolic acidosis due to underresuscitation.
Diagnosis and Treatment
In severely ill patients, endotracheal intubation should be
considered prior to EGD, especially in patients who are in
shock or unable to protect their airway. This patient is
awake and alert and has normal vital signs after fluid
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resuscitation. An EGD is performed, which reveals a large
clot and active bleeding in the first portion of the posterior
duodenum (see Figure 1).
FIGURE 1 • Endoscopic view of bleeding duodenal ulcer.
This patient is at high risk for rebleeding (active
bleeding during endoscopy—90% chance of recurrence,
visible vessel—50% chance of rebleeding, adherent clot—
25% to 30% chance of recurrence). Despite this risk,
attempts at endoscopic control of the bleeding should be
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made. Recent experience suggests that removing the clot
in order to treat the underlying ulcer can reduce the risk of
rebleeding. Studies show that epinephrine injection alone
is inferior to combined therapies with epinephrine injection
and thermal coagulation or placement of a hemoclip.
Administration of proton pump inhibitors (PPIs) has
been shown to reduce the risk of rebleeding. Most of these
studies used intravenous omeprazole, although other PPIs
can serve as reasonable alternatives. No studies have
shown that high-dose infusions are more effective than
routine intravenous doses of PPIs. In addition to PPIs, any
potentially precipitating medications such as aspirin or
nonsteroidal anti-inflammatory agents should be
discontinued. The patient should also be evaluated with
gastric biopsies for the presence of
Helicobacter pylori
as
a precipitating factor for ulcer formation.
Presentation Continued
The patient stabilizes after a total of four units of
PRBCs. Three days after his initial EGD he develops
recurrent hematemesis with an associated drop in his
blood pressure. Blood transfusion and fluids are
started.
Discussion
Based on a controlled trial that assessed efficacy of
endoscopic therapy compared to surgery for recurrent
bleeding, patients who had a second therapeutic
endoscopy had fewer complications than those who
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underwent operative intervention, although mortality was
equivalent. Given that this patient has had a recent midline
incision and has not failed a second endoscopic attempt, a
repeat EGD is indicated. In our case, at his second EGD,
the endoscopist is able to slow the bleeding down with
epinephrine injections but cannot reliably use cautery or
other methods for hemostasis.
Although endoscopy is the best initial diagnostic and
therapeutic procedure, failure to achieve hemostasis
leaves surgery and transcatheter arterial intervention (TAI)
as possible therapeutic modalities. At this point,
indications for surgery for active rebleeding from a
duodenal ulcer include hemodynamic instability or shock
despite blood transfusion, rebleeding after two attempts at
endoscopic therapy, or continued slow bleeding requiring
blood transfusion exceeding more than three units per day.
In our case, after discussion with the family and patient,
they do not wish to pursue surgery at this time and opt for
TAI. Active bleeding is identified (Figure 2A), and
successful coil embolization of the gastroduodenal artery
(GDA) is performed and the bleeding has stopped (Figure
2B). On the day of discharge, the patient has recurrent,
large-volume hematemesis with hemodynamic instability.
At this point, the patient has failed two endoscopic
therapies and angiographic embolization. Surgical
intervention is warranted. Depending on institutional
resources, this may have been the selected therapeutic
option after the second failed endoscopy.
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FIGURE 2A • Active bleeding during angiography.
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FIGURE 2B • Cessation of bleeding after embolization coils.
Surgical Approach
Much of the literature surrounding choices for operative
management for complicated peptic ulcer disease heralds
from the era that predated the use of H2-blockers and PPI
therapy. Controversy exists as to whether a definitive ulcer
operation is now required, particularly for perforated peptic
ulcers. The priority for patients undergoing operation for a
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bleeding duodenal ulcer is to control the bleeding. If the
exact site of the bleeding is not known, a longitudinal
pyloro-duodenotomy allows for inspection of the duodenal
bulb and the gastric antrum. Otherwise, the proximal
duodenum can be incised directly over the ulcer site.
Suture of the bleeding vessel in the base of the ulcer can
be performed with sutures placed superiorly and inferiorly
to the ulcer crater (Figure 3). If bleeding continues, the
GDA can be ligated superiorly to the duodenum. While
placing the sutures, the surgeon must be aware that the
common bile duct courses posteriorly, and if the location
cannot be determined, a Fogarty or similar biliary catheter
should be inserted into the duct to avoid injury. After
achieving hemostasis, attempts to approximate the ulcer
crater should be made. The longitudinal
pyloroduodenotomy should then be closed transversely to
avoid narrowing of the pylorus and duodenum (HeinekeMikulicz pyloroplasty).
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FIGURE 3 • Duodenotomy incision.
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After control of hemorrhage from the GDA, an acidreduction procedure is generally recommended for patients
with a history of refractory peptic ulcer disease (i.e., a
history of long-standing PPI use or noncompliance). The
type of procedure is dependent on patient stability and
surgeon experience. The most expeditious procedure is a
truncal vagotomy; however, if the patient has stabilized and
the surgeon is experienced, a parietal cell vagotomy (highly
selective vagotomy) is a reasonable alternative. Maneuvers
for truncal vagotomy include retracting the left lobe of the
liver for exposure. The serosa overlying the esophagus is
opened and using a combination of blunt and sharp
dissection, the esophagus is encircled with a Penrose
drain. By retracting the esophagus caudally and palpating,
the firm “violin string” of the vagus nerve is felt. The anterior
vagus is easier to find and larger. If the posterior vagus is
not felt, it may not be included in the Penrose drain
contents, and the search should continue. After
identification, the nerves should be clipped proximally and
distally and a small segment excised.
Case Conclusion
The patient undergoes exploratory laparotomy,
pyloroduodenotomy, and oversewing of a posterior
duodenal bulb ulcer (Table 1). Given his hemodynamic
instability, and the fact that he has not previously been
treated with PPIs, an acid reduction procedure is not
performed. He recovers well from surgery without
further bleeding. Gastric biopsies from his EGD return
H. pylori
positive. He is sent home on PPIs and
H. pylori
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treatment.
TABLE 1. Key Technical Steps to Maneuvers in Oversewing a Bleeding
Duodenal Ulcer
TAKE HOME POINTS
Ensure adequate intravenous access and an
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