CAUSES OF HEMATEMESIS AND MANAGEMENT OF A CASE OF HEMATEMESIS SECONDARY TO BLEEDING PEPTIC ULCER

Differential diagnosis:

Peptic disorders Duodenal ulcer Gastric ulcer Reflux esophagitis Gastritis Duodenitis

NSAIDs Associated Disorders Acute gastric mucosal lesions Portal hypertensionrelated causes Esophageal varices Gastric varices Portal hypertensive gastropathy Watermelon stomach Mallory-Weiss tear

Neoplasms of the esophagus, stomach, or duodenum Esophagitis due to infection Dieulafoys lesion Aortoduodenal fistula Angiodysplasias Crohns disease Hemobilia Hemorrhage from a pancreatic source

Peptic ulcers

An ulcer is defined as disruption of the mucosal integrity of the stomach and/or duodenum leading to a local defect or excavation due to active inflammation Harrisons
Principles Of Internal Medicine

Caused by an imbalance between the action of peptic acid and mucosal defenses

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Schwartz Principles of Surgery

Oxyntic Gastric Gland Representation

Hypotension Hematemesis Transfusion Visible vessel Ongoing bleeding Ulcer size and location

Causes of Upper GI Bleeding Requiring Hospitalization

DIAGNOSIS Peptic ulcer Gastroesophageal varices Angioma Mallory-Weiss tear Tumor Erosion Dieulafoy's lesion Other n = 948 524 (55) 131 (14) 54 (6) 45 (5) 42 (4) 41 (4) 6 (1) 105 (11)

Bleeding Ulcer- Pathogenesis

Acid-peptic erosion into the submucosal or extraluminal vessels

Forrest classification system

FI show active bleeding, FIIa visible vessel/pigmented protuberance, 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

MANAGEMENT
Therapy is based on clinical presentation and endoscopic findings. 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 upper GI haemorrhage is adequate initial and ongoing resuscitation Following resuscitation, endoscopy to assess cause and severity of the bleed, which will dictate the required intensity of therapy and predict the risk of further bleeding and/or death

Indications for surgery

The four classic indications for surgery on peptic ulcers are: Intractability Hemorrhage Perforation Obstruction.

One goal of ulcer surgery is to prevent gastric acid secretion

Goal of surgical intervention in bleeding peptic ulcer is to control hemorrhage. This may be achieved by either direct suture ligation of the bleeding vessel or, in the case of gastric ulcer, with gastric resection or ulcer excision. The role for a definitive acid-reducing procedure is a secondary, but important, objective of the surgical procedure.

Bleeding Duodenal Ulcer

Operative intervention for bleeding duodenal ulcer requires direct exposure of the ulcer in the duodenum by way of duodenotomy or duodenopyloromyotomy. They are typically located on the posterior duodenal wall, therefore direct suture ligation with a nonabsorbable suture If direct suture ligation fails to stop bleeding, fourquadrant suture ligation around the perimeter of the bleeding ulcer may be necessary to control bleeding. Rarely, these two measures fail, and ligation of the gastroduodenal artery cephalad and inferior to the duodenum may be necessary. If hemodynamically stable- antisecretory procedure planned

Bleeding Gastric Ulcer

Unlike duodenal ulcer, there is a chance that a gastric ulcer may be malignant; up to 10% of gastric ulcers prove to be a gastric adenocarcinoma or lymphoma. Rebleeding rates for gastric ulcer treated with simple ligation approach 30%. Ideally, therefore, the surgical procedure should include ulcer excision.

Surgical procedures
TRUNCAL VAGOTOMY HIGHLY SELECTIVE VAGOTOMY (PARIETAL CELL VAGOTOMY) TRUNCAL VAGOTOMY AND ANTRECTOMY Sub-TOTAL GAsTRECTOMY Surgery is generally reserved for those patients in whom endoscopic measures have failed as the primary intervention, assuming expert endoscopy is readily available.

Endoscopic procedures

Thermal energy for coagulation. Transendoscopic bipolar electrocoagulation and heater probe therapy can decrease rebleeding rates and the need for surgical intervention by up to 50%. In skilled hands, (LASER) coagulation offers similar results Injection therapy. Available sclerosing or vasoconstricting agents include absolute alcohol, epinephrine, fibrin glue, and polidocanol. Sclerosants are injected around the ulcer perimeter or visible vessel. Endoscopy is highly successful in stopping initial active bleeding, with initial success rates in more than 95% of cases in ulcers. Nevertheless, bleeding recurs in about 20% of patients, and 97% of this rebleeding occurs within 96 hours of the initial endoscopy.[20]

Endoscopy fails in about 20% of patients Repeat endoscopy may be an option- though final outcomes are worse; increased perforation risk.

Robbins Pathological Basis Of Disease

Pathophysiology

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

Perforation

Occurs in about 5% of patients Accounts for two thirds of ulcer deaths Rarely, is the first indication of an ulcer

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

Peptic gastric and duodenal ulcers most common cause of acute hemorrhage in the upper gastrointestinal tract, each accounting for about 25% of cases Bleeding ulcer is caused by acid-peptic erosion into the submucosal or extraluminal vessels. Larger arteries are associated with increased bleeding and higher morbidity and mortality rates