causes of sis and management of a case

8/3/2019 Causes of sis and Management of a Case

1/26

CAUSES OF

HEMATEMESIS AND

MANAGEMENT OF ACASE OF HEMATEMESISSECONDARY TO

BLEEDING PEPTICULCER


2/26

Differential diagnosis:

Peptic disordersDuodenal ulcerGastric ulcer

Reflux esophagitisGastritisDuodenitis


3/26

NSAIDs Associated Disorders

Acute gastric mucosal lesionsPortal hypertensionrelated causes

Esophageal varicesGastric varicesPortal hypertensive gastropathyWatermelon stomachMallory-Weiss tear


4/26

Neoplasms of the esophagus, stomach, orduodenum

Esophagitis due to infection

Dieulafoys lesionAortoduodenal fistulaAngiodysplasiasCrohns diseaseHemobiliaHemorrhage from a pancreatic source


5/26

Peptic ulcers

An ulcer is defined as disruption of themucosal integrity of the stomach and/orduodenum leading to a local defect or

excavation due to active inflammation HarrisonsPrinciples Of Internal Medicine

Caused by an imbalance between the actionof peptic acid and mucosal defenses


6/26

Screen clipping taken: 04-06-2010, 22:54

Schwartz Principles of Surgery


7/26

Oxyntic Gastric Gland Representation


8/26

Hypotension

Hematemesis

Transfusion

Visible vessel

Ongoing bleeding

Ulcer size and location


9/26

Causes of Upper GI Bleeding RequiringHospitalization

DIAGNOSIS n = 948

Peptic ulcer 524 (55)

Gastroesophageal varices 131 (14)

Angioma 54 (6) Mallory-Weiss tear 45 (5)

Tumor 42 (4)

Erosion 41 (4)

Dieulafoy's lesion 6 (1)

Other 105 (11)


10/26

Bleeding Ulcer- Pathogenesis

Acid-peptic erosion into the submucosal orextraluminal vessels


11/26

Forrest classification system

FI show active bleeding,FIIa visible vessel/pigmentedprotuberance,

FIIb ulcer with an adherent clot,FIIc ulcer with a pigmented spot,

FIII clean ulcer base, no bleeding stigmata

Rebleeding rates increase with ulcer size;ulcers greater than 2 cm in diameter are high

risk


12/26

MANAGEMENT

Therapy is based on clinical presentation and endoscopicfindings.

MEDICAL MANAGEMENT

ENDOSCOPIC THERAPY diagnostic and therapeutic

SURGICAL THERAPY

Approximately 80% of upper GI bleeds are self-limited

The initial step in management of patients with acute upperGI haemorrhage is adequate initial and ongoing resuscitation

Following resuscitation, endoscopy to assess cause andseverity of the bleed, which will dictate the required intensityof therapy and predict the risk of further bleeding and/ordeath


13/26


14/26

Goal of surgical intervention in bleeding pepticulcer is to control hemorrhage.

This may be achieved by either direct suture

ligation of the bleeding vessel or, in the case ofgastric ulcer, with gastric resection or ulcerexcision.

The role for a definitive acid-reducingprocedure is a secondary, but important,objective of the surgical procedure.


15/26

Bleeding Duodenal Ulcer

Operative intervention for bleeding duodenal ulcerrequires direct exposure of the ulcer in the duodenumby way of duodenotomy or duodenopyloromyotomy.

They are typically located on the posterior duodenal

wall, therefore direct suture ligation with anonabsorbable suture

If direct suture ligation fails to stop bleeding, four-quadrant suture ligation around the perimeter of thebleeding ulcer may be necessary to control bleeding.

Rarely, these two measures fail, and ligation of thegastroduodenal artery cephalad and inferior to theduodenum may be necessary.

If hemodynamically stable- antisecretory procedureplanned


16/26

Bleeding Gastric Ulcer

Unlike duodenal ulcer, there is a chance that agastric ulcer may be malignant; up to 10% ofgastric ulcers prove to be a gastric

adenocarcinoma or lymphoma. Rebleeding rates for gastric ulcer treated with

simple ligation approach 30%.

Ideally, therefore, the surgical procedureshould include ulcer excision.


17/26

Surgical procedures

TRUNCAL VAGOTOMY

HIGHLY SELECTIVE VAGOTOMY (PARIETAL CELLVAGOTOMY)

TRUNCAL VAGOTOMYAND ANTRECTOMY

Sub-TOTALGAsTRECTOMY

Surgery is generally reserved for those

patients in whom endoscopic measures havefailed as the primary intervention, assumingexpert endoscopy is readily available.


18/26

Endoscopic procedures

Thermal energy for coagulation.

Transendoscopic bipolar electrocoagulation and heater probetherapy can decrease rebleeding rates and the need forsurgical intervention by up to 50%.

In skilled hands, (LASER) coagulation offers similar results

Injection therapy. Available sclerosing or vasoconstrictingagents include absolute alcohol, epinephrine, fibrin glue, andpolidocanol.

Sclerosants are injected around the ulcer perimeter or visiblevessel.

Endoscopy is highly successful in stopping initial activebleeding, with initial success rates in more than 95% of casesin ulcers.

Nevertheless, bleeding recurs in about 20% of patients, and

97% of this rebleeding occurs within 96 hours of the initialendoscopy.[20]


19/26

Endoscopy fails in about 20% of patients

Repeat endoscopy may be an option- thoughfinal outcomes are worse; increased

perforation risk.


20/26

Robbins Pathological Basis Of Disease


21/26

Pathophysiology


22/26

Complications of Peptic Ulcer

Bleeding

Occurs in 15% to 20% of patients

Most frequent complication

May be life-threatening

Accounts for 25% of ulcer deaths

May be the first indication of an ulcer


23/26

Perforation

Occurs in about 5% of patients

Accounts for two thirds of ulcer deaths

Rarely, is the first indication of an ulcer


24/26

Obstruction from edema or scarring

Occurs in about 2% of patients

Most often due to pyloric channel ulcers

May also occur with duodenal ulcers

Causes incapacitating, crampy abdominal pain

Rarely, may lead to total obstruction with

intractable vomiting


25/26

Peptic gastric and duodenal ulcers mostcommon cause of acute hemorrhage in theupper gastrointestinal tract, each accounting

for about 25% of cases Bleeding ulcer is caused by acid-peptic

erosion into the submucosal orextraluminal vessels.

Larger arteries are associated withincreased bleeding and higher morbidityand mortality rates


26/26

causes of sis and management of a case

Documents