Postoperative G a s t ro i n t e s t i n a l Hemorrhage

Seon Jones,
KEYWORDS  Gastrointestinal bleeding  Hemorrhage  Postoperative complications
MD,

Addison K. May,

MD*

Significant gastrointestinal (GI) bleeding in the postoperative period is an uncommon complication of both GI and non-GI surgery. Although uncommon, the management of GI bleeding within the postoperative period is more complex than that occurring outside the perioperative period because of a larger differential for the source of bleeding and a more complex risk/benefit analysis. There is minimal published literature specific to the management of postoperative GI bleeding, and the infrequency, complexity, and variability of the clinical setting of this complication confound simplistic consideration of its cause and therapy. Postoperative GI bleeding may be considered to occur secondary to 3 scenarios: (1) those in which the surgery or complications of the surgery are the predominate pathophysiologic cause of bleeding, (2) bleeding that occurs from causes unrelated to surgery and that predominately occur serendipitously in the postoperative period, and (3) surgical stress or complications of surgery contribute to the exacerbation of a preexisting GI bleeding source. GI bleeding in the immediate or early postoperative period is more frequently the result of the first scenario outlined, particularly when the patient has a critical illness or has other postoperative complications. Thus, this article focuses on situations in which the GI bleeding occurs secondary to surgery or surgical complications, and outlines a systematic evaluation of the patient, treatment options, and assessment of risk/ benefit ratio for various treatment options. Although most occurrences of postoperative GI bleeding are self-limiting, consideration of whether or not bleeding indicates another unrecognized postoperative complication is paramount to allow appropriate therapy. Minor postoperative bleeding likely occurs frequently and without recognition. Significant GI bleeding, generally defined as overt bleeding (nasogastric drainage with coffee-ground appearance or frank blood, hematemesis, hematochezia, or melena) complicated by hemodynamic

The authors have nothing to disclose. Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 MAB, Nashville, TN 37212-3755, USA * Corresponding author. E-mail address: addison.may@vanderbilt.edu Surg Clin N Am 92 (2012) 235–242 doi:10.1016/j.suc.2012.01.002 surgical.theclinics.com 0039-6109/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.

the upper GI tract (proximal to the ligament of Treitz) is the most common site of significant postoperative GI bleeding. severity of illness. postoperative GI bleeding is not reported in case series of operative complications. Upper GI bleeding in this setting carries significant mortality. accounting for more than 80% of all cases. or requiring invasive therapeutic intervention.1 Significant bleeding has been reported to occur in 0. both enteric and nonenteric.10. INCIDENCE The incidence of postoperative GI bleeding is low but increases with increasing magnitude of the surgical intervention. a need for transfusion of blood products.2 and significant GI bleeding has been reported in up to 3% of patients undergoing percutaneous endoscopic gastrostomy procedures. A small minority of patients have GI bleeding related to sources that coincidentally occur in the postoperative period. and (3) infectious.4%–2% incidence). the incidence is also low. (2) suture-line bleeding. reported to be 4% in one series. Late bleeding complications after aortic and abdominal vascular surgical procedures also occur as a result of vascular-enteric fistulas (0.3% to 0. most cases being related to upper GI sources. depending on the number of risk factors present.6% of 2166 colorectal procedures reported in recent series3. Suture-line bleeding from hand-sewn anastomoses seems to be rare (<1%) and is difficult to identify in any large series.4 and 1. For severe bleeding that requires therapeutic intervention.12 This high incidence is hypothesized to be related to the association of vascular disease and hypoperfusion of the enteric organs in these cases. significant GI bleeding occurs in 1. inflammatory.5 Significant suture-line hemorrhage may be more common in laparoscopic left-sided colorectal resections. Pseudoaneurysm rupture with enteric communication or vascular erosion into the GI anastomosis occurs after pancreatic and hepatobiliary procedures in roughly 2% of cases. significant bleeding is uncommon. or ischemic complications.18 Mortality for .3% of patients develop GI bleeding that requires transfusion of 2 or more units of blood. In all surgical procedures.15. For colon resection with stapled colorectal anastomosis. In one large series of resections for gastric cancer. For most elective cases of GI surgery.11 The incidence of GI bleeding seems to be greater after aortic reconstruction procedures. In critically ill patients undergoing either GI tract or non-GI tract surgery. the risks and benefits of various therapeutic options must be considered in each postoperative setting. a decrease in hemoglobin of 2 g/dL or more. all secondary to upper GI sources. roughly 0. Postoperative GI bleeding is more common in critically ill than in noncritically ill postoperative surgical patients.5% to 6% of patients.12–14 These fistulas typically occur months to years after surgery and have been reported after open and endovascular aortic procedures and repair of other abdominal vascular structures.8% in older series. ranging from 20% to 30%. with up to 4% of patients developing significant GI bleeding in the early postoperative period.236 Jones & May instability.7–9 Following cardiac surgery. with significant bleeding in 0.17. and underlying comorbid conditions of the patient population.6 Significant GI bleeding also occurs after nonintestinal surgery. occurs much less frequently but is associated with significant morbidity and mortality.9% of patients after elective bariatric surgery.4% of patients experienced significant bleeding requiring intervention. 0.16 CAUSES GI bleeding in the postoperative period is predominately related to 3 causal categories including (1) stress-related mucosal damage in the upper GI tract. Although minor suture-line bleeding occurs with some frequency after GI anastomoses.

and Helicobacter pylori.10–12.Postoperative Gastrointestinal Hemorrhage 237 patients with upper GI bleeding in the postoperative period is up to 4 times that of matched patients without bleeding.16 Nearly all critically ill patients develop some degree of SRMD in the postoperative period. the current incidence of clinically significant bleeding secondary to SRMD ranges from 1. vascular-enteric communications resulting from inflammatory or infectious processes eroding into vascular structures.15. Bleeding from anastomoses that occurs after the initial postoperative period is usually secondary to an anastomotic disruption caused by infection or ischemia and mandates interventions to address the underlying cause in addition to the bleeding itself.15. usually complicating cardiac or vascular procedures. duodenum. Overt bleeding occurred in 4. and critically ill surgical patients. bleeding related to stressrelated mucosal damage (SRMD) of the stomach. but much less commonly. Suture-line bleeding of enteroenteric. as well as MalloryWeiss tears produced by postoperative vomiting or from the exacerbation of esophageal or gastric varices. SRMD As noted earlier. which is typically noted less than 48 hours after surgery. Other causes of postoperative lower GI bleeding include diverticulosis.18 Several factors are thought to contribute to the pathophysiology of SRMD. Two factors were significant in . or gastric. Of these cases. and esophagitis. splanchnic hypoperfusion seems to be the major contributor. Lower GI tract sources also cause postoperative GI bleeding. or to vascular-enteric fistulas complicating aortic and other vascular procedures. Bleeding from SRMD may result from stress-induced gastritis. Other causes of upper GI tract postoperative bleeding include suture-line bleeding. enterocolonic. rectal ulcers.16 published in 1994. the most common site of significant postoperative GI bleeding is the upper GI tract. Lower GI bleeding in the postoperative period may occur secondary to colonic ischemia. bleeding secondary to SRMD accounts for nearly all of the postoperative GI bleeding complications seen in cardiothoracic cases.19 With improved resuscitation techniques and intraoperative and postoperative management of patients. and arteriovenous malformations. reflux of upper intestinal contents into the stomach or esophagus. Major risk factors for GI bleeding from SRMD in critically ill patients were defined in a landmark study by Cook and colleagues.19 However. and esophageal erosions.5%. 674 received prophylaxis and 1578 received no prophylaxis. and exacerbation of preexisting peptic ulcer disease. all of which typically present greater than 48 hours after surgery. Of these. Of the 2252. the incidence of significant SRMD and bleeding has decreased in the past several decades. disruption of suture lines because of infection or ischemia.4% of the patient population and clinically significant bleeding occurred in 1.5% to 6% depending on the population studied. varices. stress-induced gastric and duodenal ulcers. in which 2252 patients from 4 medical-surgical ICUs were followed prospectively for evidence of overt and clinically significant GI bleeding. Although rare. The incidence of stress-related upper GI bleeding varies greatly depending on the definition used to define the complication and the severity of illness of the patient population. and esophagus is the most common source of significant GI bleeding. including mucosal ischemia resulting from splanchnic hypoperfusion. duodenal. and these cases are predominately secondary to SRMD. or colocolonic anastomoses may occur early after surgery and is usually self-limited.15 The presence of clinically significant SRMD is associated with increased length of intensive care unit (ICU) stay and up to a 4-fold increase in mortality. duodenitis. Bleeding may also occur from hemobilia after hepatic injury or instrumentation. vascular cases. gastric acid secretion.

and those with combinations of other risk factors should undergo stress ulcer prophylaxis. Initially.7%. Patients who have unstable hemodynamics. That new-onset postoperative GI bleeding may result from another unrecognized complication such as infection and sepsis should be considered. and establishment of appropriate monitoring. Gastric and intestinal ileus may delay the presentation of hematemesis. and hemodynamics  Fluid resuscitation for the restoration of intravascular volume  Transfusion of blood products based on hemodynamic response to fluid resuscitation and laboratory evaluation  Evaluation and correction of coagulation and clotting abnormalities  Identification and control of the bleeding source  Identification and treatment of disorders contributing to the bleeding source.21 A large portion of these patients had peritonitis as their admitting diagnosis. duodenal ulcer (14%). All patients should have two 18-gauge or larger intravenous catheters placed and adequate monitoring with continuous or intermittent blood pressure assessment initiated . or melena. clinically significant bleeding occurred in 3. and acute desaturation. all patients requiring mechanical ventilation. vascular access. and sepsis seemed to be a significant contributing risk factor for bleeding.1% of those without these risk factors. hematochezia. a high index of suspicion should be maintained and adequate monitoring should be instituted. all patients should undergo evaluation of their ability to safely maintain their airways without aspiration hypoxia or hypercarbia. GENERAL APPROACH TO POSTOPERATIVE GI BLEEDING Patients with overt postoperative GI bleeding should be considered to have clinically significant and potentially life-threatening bleeding until adequate data exist to determine otherwise. peritonitis. alteration in mental status.238 Jones & May multiple regression analysis: mechanical ventilation for greater than 48 hours and coagulopathy. Other risk factors identified in univariate analysis included sepsis. and trauma. Determining the significance and magnitude of bleeding may be made more complex by preexisting postoperative anemia and volume shifts. For patients with either or both of these 2 risk factors. The basic principles of management of significant postoperative GI bleeding include  Initial assessment of airway. shock. The cause of bleeding was erosive gastritis (75%). The association of postoperative GI bleeding with significantly increased mortality supports management of these patients in the ICU setting. These patients should all be considered as high risk during the intubation process because of the risk of aspiration. burns. Thus.21 Thus. those with coagulopathy. The incidence of bleeding increases with the number of risk factors present and is as high as 10% of patients with prophylaxis and 40% without prophylaxis if 3 to 6 risk factors are present. gastric ulcer (7%).20 In another study of 720 critically ill postoperative patients performed in the 1980s. 20% had overt GI bleeding and 9% had clinically significant bleeding. perioperative b-blockade that may blunt the heart rate response to acute blood loss. Hematocrit is not useful for determining the degree of hemorrhage in the acute setting because the red cell and plasma volume lost is constant. are having significant hematemesis. or who are to undergo invasive diagnostic or therapeutic procedures should be considered for placement of an endotracheal tube to prevent acute airway compromise. evaluation and establishment of adequate intravenous access. whereas bleeding occurred in only 0. preexisting liver or renal failure. and esophageal bleeding (4%). hypotension. or preexisting tachycardia resulting from pain or the systemic inflammatory response.

The diagnostic and therapeutic approach is similar. If hemodynamic response to this volume of fluid is not complete or overt ongoing hemorrhage is present. Without considering other factors. Endoscopic diagnosis of the bleeding site is the most appropriate initial localization technique in most cases and may allow therapeutic intervention with low risk. The choice of whether to perform upper versus lower endoscopy first is determined by the estimated likely source. whereas those without can generally tolerate levels as low as 6 to 7 g/dL. However. Abnormalities may require correction with fresh frozen plasma. stress-related bleeding from the upper GI tract is the most common source of blood. hemoglobin levels. estimation of the rate of bleeding is typically difficult and evidence of active hemorrhage generally mandates transfusion to higher levels. normothermia should be maintained to prevent the exacerbation of coagulopathy. During volume resuscitation. Patients undergoing significant volume resuscitation should have warm fluids instilled and blood-warming devices used. vitamin K. Patients with significant hypotension have typically lost greater than 30% of their blood volume and transfusion of blood components should be strongly considered at the time that the diagnosis of hemorrhagic shock is established. the patient’s severity of illness and risk factors for SRMD. Evaluation of coagulation and clotting profiles should be undertaken. and accompanying clinical signs and symptoms of nonbleeding complications such as infection and pancreatitis. the operation itself. but not identical. melena vs hematochezia. The authors suggest the following algorithmic approach to locate the bleeding source: 1. Patients with active cardiovascular disease are commonly transfused with a goal to maintain hemoglobin at 10 g/dL.Postoperative Gastrointestinal Hemorrhage 239 including continuous electrocardiogram and heart rate monitoring. then packed red blood cells should be transfused. and a Foley catheter to assess urine output. Serum lactate should be assessed. hematemesis. The rate and volume of transfusion is based on the patient’s hemodynamic response. For non-GI surgery in the early postoperative period. to that of GI bleeding in the nonpostoperative period because the causes are different and more frequently related to suture-line bleeding in the early postoperative period and to SRMD or postoperative complications such as infection or pseudoaneurysm formation with bleeding as a presenting manifestation. An estimation of the likely bleeding site can be formulated by considering the character of the presenting symptoms (ie. increased levels most frequently indicate inadequate organ perfusion and incomplete resuscitation even in the setting of normal hemodynamics. upper GI bleeding is more common than lower GI bleeding. Forced-air warming devices should be placed on the patient and intubated patients should have a heated humidifier used in the ventilator circuit. or clots per rectum). Initial volume resuscitation may be up to 2 L. the timing of bleeding since the index operative procedure. Patients with evidence of significant volume depletion or a change in their hemodynamics should undergo volume resuscitation with isotonic crystalloid solutions. LOCALIZATION OF THE BLEEDING SOURCE Once the patient has had adequate initial evaluation and stabilization. and the presence of active cardiovascular disease. identification of the bleeding site should be undertaken. evidence of ongoing active hemorrhage. and platelet transfusion. nasogastric tube blood. . Elderly patients and patients with preexisting or new-onset organ dysfunction or coexisting sepsis should be considered for placement of a central venous or pulmonary artery catheter and an arterial catheter for closer monitoring of end points of resuscitation.

. CONTROL OF HEMORRHAGE Three basic modalities are indicated for the control of GI hemorrhage in the postoperative period: endoscopy. a. but a lack of bloody return does not rule out duodenal bleeding. nasogastric tube placement should be performed and may assist in determining an upper GI source. The return of blood. Techniques vary depending on the clinical setting. and surgery. then subsequent studies should be chosen based on the clinical setting. Endoscopic control of suture-line bleeding in the early postoperative period is safe and effective in most patients. and the risk of ischemia. if bleeding is not visualized or appears proximal to the colon and an enteroenteric anastomosis is present. Unless clearly from a lower GI source. 4. Morbidity and mortality increase as the volume of blood loss increases. heater probe. bleeding from sources distal to the duodenum is more likely. inflammatory and infectious complications causing intermittent bleeding may be present. Computed tomography with intravenous contrast may identify inflammation. angiography may identify the source and allow therapeutic intervention. If upper and lower endoscopy do not identify the active source.5–1 mL/min). and pseudoaneurysms. coffee-ground material. the underlying disorder leading to bleeding may limit the effectiveness and should be considered. Endoscopy is the most commonly used modality for both localization and control of hemorrhage.5– 1. techniques include infusion of vasoconstrictive agents and embolization with Gelfoam. b.3–6. Endoscopic control of bleeding can be achieved through a variety of techniques including injection of epinephrine. all of which may require therapy beyond hemorrhage control. lower endoscopy should generally be performed. If clear bile is produced.1. In the early postoperative period. then bleeding from the suture line is most commonly the source. electrocoagulation. Angiographic localization may be undertaken if the rate of bleeding is thought to be significant (>0. arteriography.240 Jones & May 2. Specific surgical therapy is determined by location and clinical setting and is beyond the scope of this article. Surgical therapy is typically indicated for patients in whom bleeding cannot be controlled by other measures successfully or without significant risk and for treatment of delayed complications that present with GI bleeding.0 mL/min)22 and may be therapeutic but the risk of angiography should be weighed against relaparotomy. and coils. and banding.23–27 In the late postoperative period. However. In the late postoperative period. Endoscopic therapy may successfully control hemorrhage related to SRMD if the bleeding points are discrete and amenable to therapy. For rapidly bleeding patients (>0. If upper GI sources are not suspected or identified. and a prospectively determined plan for intervention should be set early in the course of bleeding to limit adverse outcomes. abscesses. 3. autologous clot. laser coagulation. or a lack of bile should all prompt upper endoscopy. the underlying pathophysiologic process of the bleeding may still require diagnostic evaluation and therapy. clip application. Angiography may be used to control bleeding safely using several different techniques28–31 but the risk of ischemia and contrast nephropathy must be considered. These modalities may be used in conjunction with each other to facilitate definitive control of hemorrhage and to address other underlying disorders. the need for permanent vessel occlusion.

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