SURGICAL MANAGEMENT OF
UPPER GASTROINTESTINAL
HEMORRHAGE
Jeffrey S. Bender, MD, FACS
University of Oklahoma
College of Medicine
Objectives
• Follow the changing patterns of the
disease
• Outline the current scope of the problem
• Diagnostic and non-operative modalities
• Future management
UGI Hemorrhage
• Approximately 30% decline in rate over
last 15 years
• 150,000 admissions per year
• Over $1,000,000,000 annually
• Associated with NSAID use
UGI Hemorrhage
• Mortality rate 8-10%
• >65 now comprise over 30%
• Peptic ulcer still most common cause
• Surgery now plays an adjunctive role
UGI Hemorrhage: 1985
• 40 y.o. man with known or suspected PUD
• Often significant co-morbidities (drugs,
ETOH, etc.)
• Hematemesis and hypotension
• NGT placed and volume resuscitated
UGI Hemorrhage: 1985
• EGD reveals 1.5 cm DU with visible vessel
• 6 units PRBC transfused
• OR: oversewing and vagotomy and
pyloroplasty
• Discharged home POD#4; F/U:?;
uninsured:?
UGI Hemorrhage: 2005
• 48 y.o. female s/p Roux-en-Y gastric
bypass with subsequent revision
• One day h/o abdominal pain
• CT scan: pneumoperitoneum
• OR: perforated DU: Graham patch
UGI Hemorrhage: 2005
• POD #2: intermittent BRBPR
• Volume resuscitated
• Intermittently hypotensive
• Nuclear medicine: tagged RBC scan
UGI Hemorrhage: 2005
• Suspected bleed from transverse colon
• Bleeding continues
• Arteriogram performed X 2
UGI Hemorrhage: 2005
• Occluded celiac axis
• Retrograde flow via inferior pancreatico-
duodenal artery
• Fills hepatic, left gastric, splenic arteries
• Unable to embolize 2nd branch of IPDA
UGI Hemorrhage: 2005
• OR: duodenotomy with bleeding point third
portion oversewn
• 20 units PRBC
• Fascia left open with vac sponge closure
• Fascia closed POD #4
UGI Hemorrhage: 2005
• Prolonged ICU course (30 days)
• Transferred to rehab center day #45
• Insurance: “pre-existing condition”
UGI Hemorrhage: 1985
• Personal experience
• 27 gastric resections
• 17 vagotomies
• 95th percentile
UGI Hemorrhage: 2005
• OU experience (15 chiefs, 2002-2005)
• 49 resections (3.3/resident)
• 26 operations for perforation
(1.7/resident)
• 6 vagotomies (0.4/resident)
• 2 laparoscopic resections
UGI Hemorrhage: 1985: Literature
• 10 articles in 5 major journals
• “Management of Giant Duodenal Ulcer”
• “Risks of Surgery for UGI Hemorrhage:
1972 vs. 1982”
• “Improvements in the Diagnosis and
Management of Aortoenteric Fistula”
UGI Hemorrhage: 1985: Literature
• “Changing Patterns of Gastrointestinal
Bleeding”
• “Recurrence After Parietal Cell Vagotomy”
• “Esophageal Transection Fails…Variceal
Bleeding”
• “Topical Prostaglandin E2 in…UGI
Hemorrhage”
UGI Hemorrhage: 2000’s:
Literature
• Only 3 references in same 5 journals
• “Rupture of Splenic Artery Pseudoaneurysms”
• “Modified Sugiura Procedure”
• “Effectiveness of Gastric Devascularization and
Splenectomy…Gastric Varices”
UGI Hemorrhage: 2005: Literature
• “Celiac Axis Ligation…Unmanageable UGI
Hemorrhage”
• Arterial Embolization for Dieulafoy
Bleeding”
UGI Hemorrhage: 1980’s
• Mostly gastroduodenal ulcers
• Protocol: resuscitation, early endoscopy
and operation
• 66 patients, 1986-1990
• No deaths
Bender, et al.
Am Surg 1994
UGI Hemorrhage: 1990
What Changed?
• Therapeutic endoscopy
• Discovery of the role of h. pylori
• Better acid suppression drugs
• Liver transplant
• Interventional radiology
Helicobacter Pylori
• First reported 1983 in mucosal biopsies of
patients with active gastritis
• Initially debated about role in ulcer disease
• Abundant producer of urase
• Elicits robust inflammatory response
Pharmacologic Therapy
• Oral antacids have no effect on bleeding
• H2- receptor antagonists have had 27 RCT’s
on over 2500 patients
• Marginal improvement in surgery and death
• Still widely used
Collins, et al.
NEJM, 1985
Proton Pump Inhibitors
• Appear to be effective at high doses
• Especially so with high risk patients
• Effects clouded by use of therapeutic
endoscopy
Endoscopic Therapy
• Widely accepted as most effective method
• Not only controls ulcer bleeding but prevents
rebleeding
• Decreases need for surgery
• Only meta analysis shows decrease in deaths
Cook, et al.
Gastroenterology, 1992
Thermal Therapy
• Laser (Argon and Nd: YAG)
• Monopolar electrocoagulation
• Bipolar or mulitpolar electrocoagulation
• Heater probe
Injection Therapy
• Epinephrine (1:10,000)
• Saline
• Absolute alcohol
• Water
• Sclerosing agents
Which Endoscopic Therapy?
• Injection, laser, multi- / bipolar and heater
probe equivalent
• Latter three most common (simplest)
• Combination therapy not been shown
more effective
• Rebleed rates 15-20%
Endoscopic Therapy - Questions
• Lack of standardized definitions, especially in
stigmata
• Complications: rebleeding, 20%; perforation,
1%
• Costs not defined
• Role of repeat endoscopy: planned vs.
rebleeding
Future Endoscopic Therapies
• Cryotherapy
• Clips
• Argon plasma coagulation
• Sewing
Adjunctive Therapies
• Prokinetic agents
• Octreotide
• Dedicated units
• ? Earlier surgery
Second Look Endoscopy
• Patients at high risk of rebleeding can be
identified
• Age, site, size, co-existent disease
• Baylor Bleeding Score
Endoscopic vs. Operative Treatment
• 55 patients (of 61) with arterial bleeding or
visible vessel > 2 mm
• Repeated endoscopy in 24 hrs (32) or early
operation (23)
• Gastric resection in 79%
• Rebleed: 48% endoscopy vs. 11% operation
(p=0.002)
Endoscopic vs. Operative Treatment
• 22% required operation in endoscopy
group
• Mortality: 6% endoscopy vs. 7% operation
• No subgroup or intent-to-treat analysis
• Early 1990’s
Imhof, et al.
Langenbecks Arch Surg, 2003
“Modern” Management of
UGI Hemorrhage
• Resuscitation
• High dose proton pump inhibitors
• Early endoscopy with therapeutic
intervention
• Repeat endoscopy in 2 hours for high risk
patients
“Modern” Management of
UGI Hemorrhage
• Concomitant decision by surgery and
gastroenterology regarding operation
• Most deaths still due to repeated episodes
of shock
Operation for UGI Hemorrhage
• Likely to become even less frequent
• Therefore operative mortality will likely
increase
• No need to do a curative ulcer operation
• Control hemorrhage only
Future Directions
• Further risk stratification
• Define role of angiography
• Earlier operation for those at higher risk