Bleeding Peptic Ulcer

What proportion of UGI Bleeds have a non-variceal cause?

80-90%

What are etiologic factors in the pathogenesis of peptic ulcers?

Aspirin, NSAIDS, and H. pylori

Smoking tobacco also inhibits the gastric mucosal barrier...
Remember that gastric ulcers may be secondary to underlying malignancy.

What are the types of gastric ulcers based on location?

Type I - lesser curvature / incisura
Type II - incisura + duodenum
Type III - prepyloric
Type IV - high on lesser curvature near GE junction
Type V - anywhere, secondary to NSAIDs

Types II/III are classically attributed to acid hypersecretion

What are common presenting symptoms associated with UGI Bleeding?

Hematemesis
Melena
Hematochezia with fast/severe bleeds
Orthostatic changes
Syncope
Tachycardia
Hypotension

What are initial steps of management of an UGI Bleed?

Large-bore peripheral access
Type and Cross-match blood
Obtain CBC, electrolytes, BUN, Creatinine, INR, PTT
Volume Resuscitation with crystaloid
Monitored Unit
Insert NGT - Lavage
Urgent Upper Endoscopy

What are you looking for with NG lavage?

Aspiration of bloody or coffee-ground material.
A negative lavage is indicated by aspiration of bilious material.

What is the Blatchford Score?

A risk-stratification tool that predicts the need for medical intervention in patients presenting with UGI bleed. The scale ranges from 0-23.
(1) SBP: 100-109 (1 point), 90-99 (2 points), less than 90 (3 points)
(2) BUN: 6.5-7.9 (2 points), 8.0-9.9 (3 points), 10.0-24.9 (4 points), less than 25 (6 points)
(3) Hgb - men : 12.0-12.9 (1 point), 10.0-11.9 (3 points), less than 10(6 points).
Hgb - women: 10.0-11.9 (1 point), less than 10 (6 points)
(4) Other variables: Tachycardia (1 point), Melena (1 point), Syncope (2 points), Hepatic disease (2 points), Cardiac failure (2 points)

What is the Rockall score?

A combination of clinical and endoscopic parameters that are used for risk-stratification of UGI bleed. The Scale ranges from 0-11 points.
CLINICAL :
-Age: Less tan sixty (0), 60-79y (1 point), over 80y (2 points)
-Shock: Tachycardia (1 point), SBP less than 100mmHg (2 points)
-Coexisting illness: Heart disease/CHF (2 points), Renal Failure, Hepatic Failure, or metastatic CA (3 points)
ENDOSCOPIC:
-Diagnosis: no lesion or Mallory Weiss tear (0), Peptic ulcer disease or esophagitis (1 point), UGI malignancy (2 points)
-Stigmata: Clean base, flat pigmented spot (0), UGI blood, active bleeding, visible vessel, or clot (2 points)

What is the Forrest Classification?

A classification of the likelihood of recurrent bleeding based on endoscopic appearance.
Grade IA - active spurting of blood
Grade IB - oozing of blood
Grade IIA - nonbleeding visible vessel
Grade IIB - adherent clot
Grade IIC - flat, pigmented spots
Grade III - clean-base ulcers

This is probably the only classification worth knowing... high risk lesions are Grades IA/B and IIA/B.

What is the management of high-risk lesions?

Endoscopic hemostasis
- injection therapy (vasoconstrictors, sclerosants, tissue adhesives)
- thermal therapy (heater probe, bipolar, argon plasma coagulation)
- mechanical therapy (endoscopic clips, loops, suturing/stapling devices)
Testing for H. pylori
Initiation of an IV proton pump inhibitor for 72 hrs, followed by an oral PPI
If hemodynamic stability is acheived, initiation of clear liquids 6 hrs after endoscopy.
Discontinuation of NSAIDS and antiplatelet agents.

There is no strong data to support the use of octreotide in the management of non-variceal GI bleeding.

What is the management of low-risk lesions?

Endoscopic hemostasis is not warranted
Start an oral PPI
Test for H. pylori
Initiate clear liquids after 6hrs
Discontinuation of NSAIDS and antiplatelet agents

What are predictors of re-bleeding?

History of peptic ulcer disease
Prior ulcer bleeding
Presence of shock at presentation
Active bleeding during endoscopy
Large ulcers (greater than 2cm)
Large underlying bleeding vessel (greater than 2mm diamenter)
Ulcers on the lesser curvature of stomach
Ulcers on the posterior or superior duodenal bulb

What are the benefits of using proton-pump inhibitors?

They significantly decrease the risk of ulcer rebleeding by 60%, the need for urgent surgery by 50%, and the risk of death by 57%.

What is a non-operative option for addressing an acute GI bleed that has not been identified or controlled by endoscopy?

Angiography with transcatheter embolization
- Gelfoam, polyvinyl alcohol, cyanoacrylates, coils
Success ranges from 52-94%, with recurrent bleeding requiring repeated embolization in 10% of patients.

In most institutions, this is reserved for endoscopic failures, especially in high-risk surgical candidates.

What is the operative management for a bleeding gastric ulcer?

-Distal gastric resection to include the ulcer (Antrectomy)
-For Type II/III ulcers (hypersecretors), consider adding a vagotomy to the antrectomy... otherwise, long-term acid suppression
-In high risk patients, gastrotomy with wedge resection of ulcer, or oversewing and biopsy of the ulcer may be considered

All patients should be tested for H. pylori
Gastric ulcers should always be biopsied if not excised to rule out cancer.

What is a Pauchet procedure?

An antrectomy with extension of the resection line to include the lesser curvature of the stomach in order to include an ulcer near the GE junction. A Billroth II gastrojejunostomy is commonly performed.

What is a Csendes procedure?

Resection of the gastric antrum and body up to the GE junction (subtotal gastrectomy). A Roux en Y gastrojejunostomy is performed along the resection line.

What is a Kelling-Madlener procedure?

An antrectomy, truncal vagotomy, and ulcer biopsies, while leaving a large GE junction/Type IV ulcer in place

What is a Mallory Weiss tear?

A linear mucosal tear at the GE junction.

Rarely do these require an operation...

What is a Dieulafoy's lesion?

An abnormal submucosal arteriole, usually in the proximal stomach, but can be anywhere in the GI tract.

What is the etiology of bleeding duodenal ulcers?

90% have H. pylori colonization of the antrum.
Massive bleeding is usually the result of transmural ulceration of the posterior duodenal wall, leading to erosion of the gastroduodenal artery.

What is the operative management of a bleeding duodenal ulcer?

Upper Midline Incision
Kocher maneuver to mobilize the duodenum medially
Longitudinal pyloromyotomy, extending 3cm on each side of the pylorus
Digital pressure of ulcer base to temporize bleeding
Allow resuscitation measures to catch up...
Suture ligation x2 of gastroduodenal artery proximal and distal to site of penetration
U-stitch (#3) is place medially in between to control the tranverse pancreatic branch...
Gastric antral biopsies for H. pylori
Truncal Vagotomy and Pyloroplasty

-some will forgo a V+P by controlling the ulcer through a longitudinal duodenotomy and medically treating the patient with PPIs and H. pylori eradication.
-An alternative operation that is the procedure of choice for a chronic bleeding duodenal ulcer is oversewing the ulcer then performing a V+A (truncal vagotomy and antrectomy).

The risk of ulcer recurrence after a V+A is 2%, compared to 5% after a V+P.

What is a Heineke-Mikulicz pyloroplasty?

Transverse closure of the longitudinal incision

What is a Finney pyloroplasty?

Side to side closure of elongated pyloroduodenotomy

What is a Jabouley pyloroplasty?

A gastroduodenostomy

Late... SG

References:
Gralnek IM, Barkun AN, Bardou M. Management of Acute Bleeding from a Peptic Ulcer. NEJM 2008; 359(9): 928-937.
Cameron's Current Surgical Therapy, 9th ed. (2008)