Fcb 102022

FEU – NICANOR REYES MEDICAL FOUNDATION

SURGERY B GIT BLEEDING
Michael L. Capulong, MD, FPCS, FPSGS
ACUTE GI BLEEDING
- Acute gastrointestinal (GI) hemorrhage is a common clinical problem
with diverse manifestations.
- The bleeding may range from trivial to massive and can originate from
almost any region of the GI tract, including the pancreas, liver, and
biliary tree.
- Hemorrhage can originate from any region of the GI tract and is
typically based on the location relative to the Ligament of Trietz.
UPPER GI BLEEDING (UGIB) • Peptic Ulcer Disease
proximal to the ligament of Trietz • Variceal Bleeding
LOWER GI BLEEDING (LGIB) • Diverticula Angiodysplasia
colon (more common: SI)
- 85%: cases stop bleeding spontaneously
- 15% cases: require emergent resuscitation, evaluation, and treatments;
usually elderly patients or with comorbidities

GIT BLEEDING
• In patients with GI bleeding,
several fundamental
principles of initial
evaluation and management
must be followed.
• Rapid initial assessment
permits a determination of
the urgency of the situation.
• Resuscitation is initiated with • What will be the guide in identifying the area of bleed?
stabilization of the patient’s o The presence and absence of fresh blood in the stool i.e.
hemodynamic status and the hematochezia, melena, coffee ground, etc.
establishment of a means for • If there is UGIB, do endoscopy within 24 hours. It can be diagnostic or
monitoring ongoing blood non-diagnostic. Why not immediately ? Da Pat free fm active bleeding
loss. o Diagnostic: be able to see the area of bleeding
• A careful history and o Therapeutic: be able to cauterize/clip the bleed and inject
physical examination should epinephrine to stop the bleeding
provide clues to the cause o Non-diagnostic: slow hemorrhage à RBC scan/tagging to
and source of the bleeding pinpoint the exact location of the bleed or massive hemorrhage
and identify any ® angiography operation
complicating conditions or • For LGIB, mainstay would be colonoscopy. It is the same as UGIB in
medications. Specific terms of diagnostic/non-diagnostic.
investigation should then proceed to refine the diagnosis.
• Therapeutic measures are then initiated, and bleeding is controlled ACUTE UPPER GASTROINTESTINAL HEMORRHAGE
and recurrent hemorrhage prevented. • Upper GI refers to the bleeding that arises from the GI tract proximal
to the ligament of Trietz and accounts for nearly 80% of significant
GI hemorrhage.
• The causes of upper GI bleeding are best categorized as either
nonvariceal sources or bleeding related to portal hypertension.
• The nonvariceal causes account for approximately 80% of such
bleeding, with PUD being the most common.
• Although patients with cirrhosis are at high risk for development of
variceal bleeding, nonvariceal sources can account for up to 50% of
GI bleeds.
• However, because of greater morbidity and mortality of variceal
bleeding, patients with cirrhosis should generally be assumed to have
variceal bleeding and appropriate therapy initiated until an emergent
endoscopy has demonstrated another cause for the hemorrhage.
• The foundation for the diagnosis and management of patients with
an upper GI bleed is an upper endoscopy.
Algorithm for the diagnosis of acute GI hemorrhage.
• Subsequent evaluation depends on the results of the upper
endoscopy and the magnitude of the bleeding. Angiography or even ACUTE LOWER GASTROINTESTINAL HEMORRHAGE
surgery may prove necessary for massive hemorrhage, precluding • The mortality rate of lower GI bleeding is similar to that of upper
endoscopy, from either the upper or lower GI tract. GI bleeding at around 3%, but this rate increases with age to
• For slow or intermittent bleeding from the lower GI tract, colonoscopy more than 5% in those 85 years or older.
is now the initial diagnostic maneuver of choice. When endoscopy is • In more than 95% of patients with lower GI bleeding, the source
non-diagnostic, the tagged RBC scan is usually employed. of hemorrhage is the colon.
• For obscure bleeding, usually from the small bowel, the capsule • The small intestine is only occasionally responsible, and because
endoscopy is becoming the appropriate study. Once the bleeding has these lesions are not typically diagnosed with the combination of
been identified, appropriate therapy can be initiated. upper and lower endoscopy, they are considered in the section
on obscure causes of GI bleeding.
• In general, the incidence of lower GI bleeding increases with
age, and the cause is often age related.

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 DIFFERENTIAL DIAGNOSIS OF LOWER GASTROINTESTINAL - Bleeding stops spontaneously
SURGERY B
HEMORRHAGE - Upper endoscopy confirms the suspicion à one or more longitudinal
COLONIC BLEEDING 90% SMALL BOWEL BLEEDING 5% fissures in the mucosa of the herniated stomach as the source of
Diverticular Disease 30-40% Angiodysplasias bleeding
Anorectal Disease 5-15% Erosions or ulcers (potassium, - Controlled by balloon tamponade
Ischemia 5-10% NSAIDS) - Vasopressin infusion vasoconstriction
-

Neoplasia 5-10% Crohn’s disease - Endoscopic injection of epinephrine may be therapeutic if bleeding
Infectious Colitis 3-8% Radiation does not stop spontaneously
Post-polypectomy 3-7% Meckel’s diverticulum - Surgical: laparotomy and high gastrotomy with oversewing of the
Inflammatory Bowel Disease 3-4% Neoplasia linear tear
Angiodysplasia 3% Aortoenteric fistula
Radiation colitis or proctitis. 1-3%
Other 1-5% BLEEDING PEPTIC ULCER
Unknown 10-25% - Bleeding is the most common cause of ulcer-related death
- MOST COMMON cause of Upper GI Bleeding 75% of patients will
ENDOSCOPY stop bleeding
Algorithm for the diagnosis and management of nonvariceal upper GI - 25% continue to bleed or rebleed (Mortalities occur In this group)
bleeding. - Early endoscopy needed to diagnose and assess any Hemodynamic
• As stated previously, therapy
patients with clinical - Persistent bleeding or rebleeding after endoscopic therapy
evidence of a GI bleed Indication for repeat endoscopic treatment
should receive an
endoscopy within 24 RISK-STRATIFICATION TOOLS FOR UPPER GASTROINTESTINAL
hours, and while awaiting HEMORRHAGE
the EGD, they should be A. BLATCHFORD SCORE
treated with a PPI. AT PRESENTATION POINTS
• After the index endoscopy, Systolic blood pressure
treatment strategies 100–109 mmHg 1
depend on the 90–99 mmHg 2
appearance of the lesion <90 mmHg 3
at endoscopy. Blood urea nitrogen
• Endoscopic therapy is 6.5–7.9 mmol/L 2
instituted If bleeding is 8.0–9.9 mmol/L 3
active or, when bleeding 10.0–24.9 mmol/L 4
has already stopped, if ≥25 mmol/L 6
there is a significant risk of Hemoglobin for men
re-bleeding. The ability to 12.0–12.9 g/dL 1
predict the risk of re-
10.0–11.9 g/dL 3
bleeding permits
<10.0 g/dL 6
prophylactic therapy,
Hemoglobin for women
closer monitoring, and earlier detection of hemorrhage in high-risk
patients. 10.0–11.9 g/dL 1
• The Forrest Classification was developed in an attempt to assess <10.0 g/dL 6
this risk on the basis of endoscopic findings and to stratify the Other variables at presentation
patients into low-, intermediate-, and high-risk: Pulse ≥100 beats/min 1
o Forrest I-IIa: endoscopic therapy is recommended in cases of Melena 1
active bleeding as well as for a visible vessel Syncope 2
o Forrest IIb: cases of an adherent clot; the clot is removed and Hepatic disease 2
the underlying lesion is evaluated; typically seen Cardiac failure 2
o when there is spontaneous stopping of bleeding B. ROCKALL SCORE better in assessing outcome
-

o Forrest IIb, IIc, and III: typically, can be managed VARIABLE PTS
o medically i.e. PPIs and test the presence of H. Pylori Age
o Forrest Ia, Ib, and IIa: warrants surgical intervention <60 y 0
The Forest Classification for Endoscopic Findings and Rebleeding 60–79 y 1
Risks in Peptic Ulcer Disease ≥80 y 2
CLASSIFICATION REBLEEDING RISK Shock
Grade Ia active, pulsatile bleeding High CLINICAL Heart rate >100 beats/min 1
ROCKALL
Grade Ib active, non-pulsatile bleeding High SCORE Systolic blood pressure <100 2
Grade IIa non-bleeding visible vessel High mmHg
Grade IIb adherent clot Intermediate Coexisting illness
Grade IIc ulcer with black spot Low Ischemic heart disease, congestive heart 2
COMPLETE
Grade III clean, non-bleeding ulcer bed Low failure, other major illness
ROCKALL
SCORE Renal failure, hepatic failure, metastatic 3
cancer
MALLORY – WEISS SYNDROME
Endoscopic diagnosis
- Acute upper GI bleeding following vomiting, is considered to be the No lesions observed, Mallory-Weiss 0
cause of up to 15% of all severe upper GI bleeds. syndrome Peptic ulcer, erosive disease, 1
- Mechanism is similar to spontaneous esophageal perforation: an esophagitis Cancer of the upper GI tract 2
acute increase in intra-abdominal pressure against a closed glottis in
Endoscopic stigmata of recent
a patient with a hiatal hernia.
hemorrhage 0
o Vomiting is not an obligatory factor, as there may be other
Clean base ulcer, flat pigmented spot 2
causes of an acute increase in intra-abdominal pressure, such
Blood in upper GI tract, active bleeding,
as paroxysmal coughing, seizures, and retching
visible vessel, clot
- Mucosal tears in the GEJ (gastroesophageal junction)
- Can also follow from paroxysmal coughing, retching and seizures

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MANAGEMENT Algorithm for the treatment of bleeding peptic ulcer.
SURGERY B
- PPIs are the mainstay of medical therapy for PUD, but high dose
H2RAs and sucralfate are also quite effective. Patients hospitalized Hospital admission Bleeding peptic ulcer

for ulcer complications should receive PPI by continuous IV infusion

and, when discharged, should be considered for life- long PPIs
unless the definitive cause is eliminated or a definitive operation Resuscitate
Continuous IV PPI drip
performed. EGD
- If H. pylori infection is documented, it should be treated with one of
several acceptable regimens
- Long-term maintenance PPI therapy should be considered in all 20% high risk 80% Low risk
patients admitted to hospital with ulcer complications, all high-risk
patients on NSAIDs or aspirin (the elderly or debilitated), and all
patients with a history of recurrent ulcer or bleeding Yes Shock? No

Yes Transfusion? No
Treatment regimens for Helicobacter pylori Yes Active bleeding on EGD? No
MEDICATIONS/DOSE/FREqUENCy DURATION
Yes Visible vessel on EGD? No
PPI + clarithromycin 500 mg bid + amoxicillin 1000 mg bid 10–14 d
Yes Abnormal PT, PTT, or platelets? No
PPI + clarithromycin 500 bid + metronidazole 500 bid 10–14 d
PPI + amoxicillin 1000 mg bid, then 5d
PPI + clarithromycin 500 mg bid + tinidazole 500 mg bid 5d Endoscopic hemostatic Rx
Bleeding stops
Salvage regimens for patients who fail one of the above initial Consult surgeon

regimens:
Bismuth subsalicylate 525 mg qid + metronidazole 250 10–14 d Bleeding recurs Lifelong PPI
mg qid + tetracycline 500 mg qid + PPI in hospital Test + Rx H. pylori
Avoid NSAIDs/ASA if possible
PPI + amoxicillin 1000 mg bid + levofloxacin 500 mg daily 10 d
PPI = proton pump inhibitor. Source: Data from Chey et al.63
Bleeding persists
>4 PRBC transfused/24h
SURGICAL INTERVENTION Deep ulcer eroding big vessel Discharge
Hemodynamic instability
- Criteria for Bleeding Peptic Ulcer Surgical Intervention: Hemostatic Rx unavailable
o 2 endoscopic failures
o Elderly patients and patients with multiple comorbidities Bleeding recurs

o Deep bleeding ulcers on the posterior bulb or lesser gastric O.R.

curvature
- Indications for Immediate Surgery in GI Bleeding: All Algorithm
Figure 26-42. patientsforadmitted
the treatmentto hospital
of bleeding with
peptic bleeding
ulcer. peptic ulcer
ASA = acetylsalicylic should
acid; EGD be
= esophagogastroduodenoscopy;
o Hemodynamic instability despite vigorous resuscitation (>6- O.R. = operating room; PPI =resuscitated
adequately proton pump inhibitor;
andPRBC = unit of
started onpacked red blood cells;
continuous PT = prothrombin
IV PPI.72 time; PTT = partial throm-
Seventy-five
boplastin time; Rx = treatment.
unit transfusion) percent of patients will stop bleeding with these measures alone, but 25%
o Failure of endoscopic techniques to arrest hemorrhage will continue to bleed or will rebleed in hospital. It is important to identify
o Recurrent hemorrhage after initial stabilization (with up to this high-risk
The standard group
operation for earlyPUD
obstructing with clinical andbecause
is vagotomy endoscopic parameters
of intractable PUD should raisebecause,
red flags for the sur-
two attempts at obtaining endoscopic hemostasis) and antrectomy. Alternatively vagotomy and gastrojejunostomy
essentially, all the deaths from bleeding geon: Maybe the patient has a missed cancer; maybe the patient
ulcer occur in this group. Surgical
should be considered if a difficult duodenal stump is anticipated is noncompliant (not taking prescribed PPI, still taking NSAIDs,
o Shock associated with recurrent hemorrhage consultation
with resection. is mandatory,
HSV and gastrojejunostomy may and endoscopic
be compara- still hemostatic
smoking); maybetherapy
the patient(cautery,
has Helicobacter despite the
o Continued slow bleeding with a transfusion requirement ble to V+Aepinephrine injection,
for obstructing ulcer disease, clipping)
76
and sometimesis indicated
has andofusually
presence successful
a negative in these
test or previous treatment. Because
exceeding 3 units/day appeal because it can be done laparoscopically, and because
high-risk patients.73,74 Indications for operation acid secretion can be totally blocked and H. pylori eradicated
include massive
it does not complicate future resection, if needed. However, with modern medication, the question remains: “Why does the
potentially hemorrhage
curable gastric orunresponsive
duodenal cancers canto endoscopic
be missed control,
patient have and transfusion
a persistent ulcer diathesis?” The surgeon should
SURGICAL TECHNIQUE: requirement of more than four to six unitsreview
with this approach. of blood, despite
the differential attempts
diagnosis at ulcer before any
of nonhealing
- Suture ligation of the bleeder endoscopic control. Lack consideration
of availability of a therapeutic of operative treatment (Table 26-13).
endoscopist,
Intractable or Nonhealing Peptic Ulcer Surgical treatment should be considered in patients with
- Suture ligation and non - resective ulcer operation (HSV or V + D) Intractabilityrecurrent hemorrhage
should be an unusual indicationafter one or
for peptic more nonhealing
ulcer attemptsor at endoscopic
intractable PUD whocontrol,
have multiple recurrences,
- Gastric resection (vagotomy and ulcer resection) lack of The
operation nowadays. availability offor
patient referred blood
surgicalfor transfusion,
evaluation largerepeat
ulcers (>2hospitalization for
cm), complications (obstruction, perforation, or
o Gastric ulcer requires biopsy if not resected. bleeding ulcer, and con- current indications for surgery such as perforation
or obstruction, are also indications for surgery. Patients with massive
Surgical options in the treatment of duodenal and gastric ulcer bleeding from high-risk lesions (e.g., posterior duodenal ulcer with erosion
INDICATION DUODENAL GASTRIC of gastroduodenalartery, or lesser curvature gastric ulcer with erosion of
Bleeding 1. Oversewa 1. Oversew and biopsya left gastric artery or branch) should be considered for early operation. Early
2. Oversew, V + D 2. Oversew, biopsy, V + D operation should also be considered in patients more than 60 years of age,
3. V + A 3. Distal gastrectomyb those presenting in shock, those requiring more than four units of blood in
Perforation 1. Patcha 1. Biopsy and patcha 24 hours or eight units of blood in 48 hours, those with rebleeding, and
2. Patch, HSV 2. Wedge excision, V + D those with ulcers >2 cm in diameter. The mortality rate for surgery for
3. Patch, V + D 3. Distal gastrectomyb bleeding peptic ulcer is around 20%. Angiography and embolization may
Obstruction 1. HSV + GJ 1. Biopsy; HSV + GJ be useful in some patients.
2. V + A 2. Distal gastrectomyb
Intractability/ 1. HSVb 1. HSV and wedge
nonhealing 2. V + D 3. V + A excision
2. Distal gastrectomy
a Unless the patient is in shock or moribund, a definitive procedure should be
considered.
b Operation of choice in low-risk patient.
GJ = gastrojejunostomy; HSV = highly selective vagotomy; V + A = vagotomy and
antrectomy; V + D = vagotomy and drainage.

LOWER GI BLEEDING
MECKEL’S DIVERTICULUM
- Most common congenital anomaly of the GIT
- TRUE Diverticula - their walls contain all of the layers found in
normal small intestine
- 60% contain heterotopic mucosa
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 o over 60% consist of gastric mucosa -
Diagnosis SURGERY B
Rarely diagnosed prior to surgical intervention DX When

o Pancreatic acini (next most common) - Incidental finding during endoscopy or radiology symptomatic
o Others: Brunner’s glands, pancreatic islets, colonic mucosa, - Enteroclysis - accuracy of 75% but is usually not applicable during
endometriosis, and hepatobiliary tissues acute presentations of complications related to Meckel’s diverticula
- Radionuclide scans - helpful in the diagnosis of Meckel’s
“RULE OF TWOS” diverticulum
- 2% prevalence o this test is positive only when the diverticulum contains
- 2:1 MALE predominance associated ectopic gastric mucosa that is capable of uptake
- 2 feet from ileocecal valve (Location) of the tracer
o usually found in the ileum within 100 cm of the ileo- cecal o accuracy
valve § 90% in pediatric pxs
- Half are asymptomatic under 2 yrs. old § less than 50% in adults

TREATMENT
- Recommended: diverticulectomy with removal of associated bands
connecting the diverticulum to the abdominal wall or intestinal
mesentery
- For bleeding, segmental resection of ileum that includes both the
diverticulum and the adjacent ileal peptic ulcer should be
performed
o may also be necessary if the diverticulum contains a tumor or
if the base of the diverticulum is inflamed or perforated
PATHOPHYSIOLOGY - Management of incidentally found Meckel’s is controversial
- During the eighth week of gestation, the omphalomesenteric
(vitelline) duct normally undergoes obliteration. ACQUIRED DIVERTICULA
- Failure or incomplete obliteration of the vitelline duct à Most
- False diverticula à their walls consist of mucosa and submucosa
commonly, Meckel’s Diverticulum
but lack a complete muscularis
- Other abnormalities
- Asymptomatic unless complications arise
o Formation of omphalomesenteric fistula
- More common in the duodenum near the ampulla à known as
o Enterocyst
periampullary, juxtapapillary, or perivaterian diverticula
o Fibrous band connecting the intestine to the umbilicus
- Prevalence
- Bleeding associated with Meckel’s diverticulum à usually the
o duodenal diverticula: 0.16% - 6%
result of ileal mucosal ulceration that occurs adjacent to acid-
§ rare in patients under 40 years.
producing, heterotopic gastric mucosa located within the
§ mean age of diagnosis: 56 - 76 years
diverticulum.
o jejunoileal diverticula: 1% to 5%.65
- Meckel’s diverticula can be found in inguinal or femoral hernia sacs
§ prevalence increased w/age; sixth and seventh
(known as Littre’s hernia). These hernias, when incarcerated, can
decades of life
cause intestinal obstruction.
- Jejunoileal diverticula
o 85% jejunum
CLINICAL PRESENTATION
o 15% ileum
- Asymptomatic unless complications arise
o 5% both
- Lifetime incidence rate of complications is 4% to 6%
- Diverticula in the jejunum tend to be large and accompanied by
- MOST common presentation
multiple other diverticula
o Bleeding (Most common in children less than 18yrs)
- Those in the ileum tend to be small and solitary
§ rare among patients older than 30 yrs
- Pathophysiology:
o Intestinal Obstruction (Adults)
o hypothesized to be related to acquired abnormalities of
o Diverticulitis (20% symptomatic patients)
intestinal smooth muscle or dysregulated motility à herniation
§ associated with a clinical syndrome that is
of mucosa and submucosa through weakened areas of
indistinguishable from acute appendicitis
muscularis
- Carcinoid tumors present in 0.5% to 3.2% of resected diverticuli
o can lead to bacterial overgrowth, leading to vitamin B12
- Common neoplasm seen
deficiency, megaloblastic anemia, malabsorption, and
steatorrhea

OBSCURE GI BLEEDING
- GI Bleeding with no source identified
o Overt GI bleeding - presence of hematemesis, melena, or
hematochezia.
o Occult GI bleeding - occurs in the absence of overt bleeding
and is identified on laboratory tests (e.g., iron-deficiency
anemia) or examination of the stool (e.g., positive guaiac
Causes of Obstruction: test)
1. Volvulus of the intestine around the fibrous band attaching the - Occult in 20% of cases
diverticulum to the umbilicus - Small intestinal angiodysplasia account for approximately 75% of
2. Entrapment of intestine by a mesodiverticular cases in adults
3. Intussusception with the diverticulum acting as a lead point - Neoplasms account for 10% of cases
4. Stricture secondary to chronic diverticulitis - Meckel’s diverticulum MOST COMMON in children
Meckel 's - Other Sources
fibrous
o Chron’s disease
band o NSAID induced ulcers and erosions
o Infectious enterides
o Vasculitis, Ischemia
o Intussusception
intussusception
DIAGNOSIS

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 Diagnostic and management algorithm for obscure gastrointestinal return of bile suggests that the source of bleeding is distal to
o
SURGERY B
(GI) bleeding. the ligament of Treitz.
- 1169If aspiration reveals blood or non- bile secretions, or if symptoms
Obscure gastrointestinal bleeding
suggest an upper intestinal source, esophagogastroduodenoscopy
is performed.
Rule out upper and lower GI - Anoscopy and/or limited proctoscopy - can identify hemorrhoidal
bleeding;
EGD and colonoscopy bleeding.
- Technetium-99 (99mTc)-tagged red blood cell (RBC) scan -
Minor bleeding Major bleeding extremely sensitive and is able to detect as little as 0.1 mL/h of
bleeding; however, localization is imprecise.

CHAPTER 28 SMALL INTESTINE

(intermittent) (persistent)

o Positive: angiography can then be both diagnostic and

Small bowel Stable Unstable potentially therapeutic.
series Negative
Enteroclysis and - If the patient is hemodynamically stable, a rapid bowel preparation
Enteroscopy
Capsule
patient stable
Tagged Operating
(over 4–6 hours) can be performed to allow colonoscopy.
endoscopy RBC scan room - Colonoscopy – may identify the cause of the bleeding
Positive Negative Positive o cautery or injection of epinephrine into the bleeding site may be
Initiate appropriate
Repeat EGD/
Angiography Source Source of
used to control hemorrhage.
Colonoscopy if
therapy
rebleeds
and treatment uncertain bleeding identified - Colectomy - may be required if bleeding persists despite
interventions.
Localize bleeding: Treat source eg.
- Intraoperative colonoscopy and/or enteroscopy - may assist in
Serial clamping or intraoperative small bowel localizing bleeding.
enteroscopy followed by resection resection
- If colectomy is required, a segmental resection is preferred if the
-
Figure 28-29. Enteroscopy
Diagnostic is playing
and management anforincreasingly
algorithm important
obscure gastrointestinal role.
(GI) bleeding. EGD = esophagogastroduodenoscopy; bleeding source can be localized.
RBC = red
- bloodSeveral
cell. endoscopic techniques for visualizing the small intestine: - “Blind” subtotal colectomy - may very rarely be required in a patient
o push enteroscopy,
injury, Meckel’s and acquired diverticula, neoplasms (especially fever and tachycardia. Plain abdominal radiographs may reveal who is hemodynamically unstable w/ ongoing colonic hemorrhage of
o
lymphoma, adenocarcinoma, Sonde enteroscopy,
and melanoma), and foreign bodies. free intraperitoneal air if intraperitoneal perforation has occurred. an unknown source.
Among iatrogenic injuries, duodenal perforation dur- If perforation is suspected but not clinically obvious, CT scan-
o intraoperative enteroscopy,
ing ERCP with endoscopic sphincterotomy (ES) is the most ning should be performed. Jejunal and ileal perforations require
o prior to proceeding, it is crucial to irrigate the rectosigmoid
o
common. This complication double-
occurs inballoon
0.3% to 2.1% endoscopy,
of cases. surgical repair or segmental resection. o re-examine the mucosa of the anal canal and rectum by
Patients who have o undergone
wirelessBillroth II gastrectomy
capsule are at
enteroscopy anoscopy and proctoscopy to ensure the source of ongoing
increased risk of duodenal perforations as well as free jejunal Chylous Ascites
Push
perforations enteroscopy
during ERCP. Although ERCP-related duodenal Chylous ascites refers to the accumulation of triglyceride-rich bleeding is not distal to the planned resection margin).
- canadvancing
perforations a long endoscope
result in a free perforation, most are retroperi-(suchperitoneal
as a pediatric
fluid with aor adult
milky or creamy appearance, caused - Occult blood loss from GIT à may manifest as iron-deficiency
toneal. Manifestations of such contained duodenal perforations by the presence of intestinal lymph in the peritoneal cavity.
following ERCPcolonoscope
can resemble thoseor a specialized
of ERCP-induced pancre-instrument) beyond
Chylomicrons, produced the ligament
by the intestine andof
secreted into lymph anemia or may be detected with FOBT.
atitis, including Treitz into the proximal jejunum
hyperamylasemia. during the absorption of long-chain fatty acids, account for the o Because colon neoplasms bleed intermittently and rarely
CT scanning is the most sensitive test for diagnosing duo- characteristic appearance and triglyceride content of chyle.
- allow for visualization of approximately
denal perforations; positive findings include pneumoperitoneum
60 cm of the proximal jejunum
The most common etiologies of chylous ascites in Western
present with rapid hemorrhage, the presence of occult fecal
for free-perforations,
Diagnostic yield: 3%
but more commonly to 65%. air,
retroperitoneal countries are abdominal malignancies and cirrhosis. In Eastern blood should always prompt a colonoscopy.
contrast-extravasation,
Alsp and paraduodenal
allows fluid collections. If of
for cauterization and developing
all bleeding sites.countries, infectious etiologies, such as tuber- o Unexplained iron-deficiency anemia is also an indication for
patients undergoing a therapeutic ERCP are imaged with a CT culosis and filariasis, account for most cases. Chylous ascites
scan following the procedure, up to 30% will have evidence of can also develop as a complication of abdominal and thoracic colonoscopy.
Sonde
air in the enteroscopy
retroperitoneum, but the majority are asymptomatic. operations and trauma. Operations particularly associated with - Hematochezia is commonly caused by hemorrhoids or a fissure.
These patients do not require any specific therapy.70 this complication include abdominal aortic aneurysm repair,
- casesaoflong,
True thin fiberoptic
retroperitoneal perforations ofinstrument
the duode- is retroperitoneal
propelledlymph through the intestine
node dissection, bycava resec-
inferior vena o Sharp, knife-like pain and bright red rectal bleeding with bowel
peristalsis
num can be managed following
nonoperatively, inflation
in the absence of a balloon
of progres- at transplantation.
tion, and liver the instrument’s tip of chylous asci-
Other etiologies movements suggest the diagnosis of fissure.
sion and sepsis. However, intraperitoneal duodenal perforations tes include congenital lymphatic abnormalities (e.g., primary
- Visualization is done during instrument
require surgical repair with pyloric exclusion and gastrojejunos-
withdrawal; approximately
lymphatic hypoplasia), radiation, pancreatitis, and right-sided
o Painless, bright red rectal bleeding with bowel movements is
50% to 75%
tomy or tube duodenostomy. of the
Iatrogenic small-intestinal
small bowel perfora- mucosa
heart failure.can be examined. often secondary to a friable internal hemorrhoid that is easily
tion incurred
- during endoscopy, if immediately recognized, can
Limitations: Three mechanisms have been postulated to cause chylous detected by anoscopy.
sometimes be repaired using endoscopic techniques. ascites: (a) exudation of chyle from dilated lymphatics on the
Perforation o Lacksandbiopsy
of the jejunum or therapeutic
ileum occurs into the peri- capability
wall of the bowel and in the mesentery caused by obstruction o In the absence of a painful, obvious fissure, any patient with
toneal cavity and o Lacksovert
usually causes tipsymptoms
deflection capability,
and signs, such limitingvessels
of lymphatic complete
at the basemucosal
of the mesentery or the cisterna rectal bleeding should undergo a careful digital rectal
as abdominal pain, tenderness, and distention accompanied by chili (e.g., by malignancies); (b) direct leakage of chyle through
visualization examination, anoscopy, and proctosigmoidoscopy.
o Failure to diagnose a source in the distal anorectum should
Wireless capsule enteroscopy prompt colonoscopy.
1184
- Relies on a radiotelemetry capsule enteroscope that is small enough Acute colonic bleeding

to swallow and has no external wires, fiberoptic bundles, or cables

- While the capsule is being propelled through the intestine by Volume resuscitation
plus blood transfusion

peristalsis, video images are transmitted using radiotelemetry to an NG aspirate

NG aspirate
array of detectors attached to the patient’s body. negative positive

o detectors capture the images and permit continuous Proctoscopy Gastroduodenoscopy

triangulation of the capsule location in the abdomen, Rule out anorectal bleeding + endoscopic treatment
PART
UNIT II

Bleeding stopped or slowed down Massive life-threatening bleeding

facilitating the localization of lesions detected Elective colonoscopy Mesenteric arteriography

Positive Negative Positive Negative

Capsule endoscopy Endoscopic

treatment
Observe Moderate bleeding
continued
Vasopressin
or emboli
Explore, intraoperative
endoscopy
SPECIFIC CONSIDERATIONS

- For patients who are hemodynamically stable but continues to bleed. Rebleeding
Rebleeding
Fail Positive Negative

- Success rates as high as 90% in identifying a small bowel pathology. Segmental

resection
See moderate bleeding
or massive bleeding
Segmental
resection
Segmental
resection
Total
colectomy

- The inability to perform biopsies or carry out any therapeutic

or
interventions of capsule endoscope likely prevents the improved 99MTc RBC scintigraphy Urgent colonoscopy

diagnostic yield of the test Positive Negative

Positive Negative

Mesenteric arteriography Explore, intraoperative Colonoscopic treatment Explore, intraoperative

endoscopy or explore, segmental endoscopy
Positive Negative resection
LOWER GI BLEEDING Vasopressin Explore, intraoperative
Positive Negative Positive Negative
Segmental Total Segmental Total
- The first goal in evaluating and treating a patient with gastrointestinal or emboli
Fail
endoscopy
Positive Negative
resection colectomy resection colectomy

hemorrhage is adequate resuscitation. Segmental Segmental Total

resection resection colectomy
o ensuring a patent airway
o supporting ventilation, Algorithm for treatment
Figure 29-7. Algorithm of colorectal
for treatment of colorectal hemorrhage. NG hemorrhage. (Schwartz)
= nasogastric; Tc = technetium-99; RBC = red blood cell. 99m

o optimizing hemodynamic parameters apply, (Reproduced with permission of Taylor & Francis, LLC from Gordon PH, Nivatvongs S, eds. Principles and Practice of Surgery for the
For
Colon,patients in whom
Rectum, and Anus. 2nd ed. Newbleeding from
York: Marcel Dekker, Inc.;an obscure
1999:1279. GIconveyed
Permission source has
through apparently
Copyright Clearance Center,
o coagulopathy and/or thrombocytopenia should be corrected stopped,
Inc.)
push enteroscopy or capsule enteroscopy is a reasonable initial
- The second goal is to identify the source of hemorrhage. study.
movements, Ifhard
thesestools,examinations do
or excessive straining. A nothis-reveal
careful a potential
(colonic source
inertia) refractory to maximalofmedical
bleeding,
interventions.
tory of these symptoms often clarifies the nature of the problem. While this operation almost always increases bowel movement
- Most common source of GIT hemorrhage: esophageal, gastric, or thenConstipation
enteroclysis has manyshould be performed.
causes. Underlying metabolic, Standard small
frequency, complaints bowel
of diarrhea, follow-
incontinence, and abdominal
duodenal through
pharmacologic, examinations are associated
endocrine, psychological, and neurologic with a low
pain are diagnostic
not infrequent, and patientsyield
should bein this selected
carefully
causes often contribute to the problem. A stricture or mass and counseled. 15

o nasogastric aspiration should always be performed lesion should be excluded by colonoscopy, barium enema, or
CT colonography. After these causes have been excluded, eval-
5⏐6 uation focuses on differentiating slow-transit constipation from
liv outlet obstruction. Transit studies, in which radiopaque markers
are swallowed and then followed radiographically, are useful for
diagnosing slow-transit constipation. Anorectal manometry and
Diarrhea and Irritable Bowel Syndrome. Diarrhea is also
a common complaint and is usually a self-limited symptom of
infectious gastroenteritis. If diarrhea is chronic or is accompa-
nied by bleeding or abdominal pain, further investigation is
warranted. Bloody diarrhea and pain are characteristic of colitis;
setting and should be avoided. If still no diagnosis has been made, a
SURGERY B
DIVERTICULAR DISEASE
“watch-and-wait” approach is reasonable, although angiography should be - Result from erosion of the peridiverticular arteriole
considered if the prior episode of bleeding was overt. Angiography can - Most significant in elderly patients
reveal angiodysplasia and vascular tumors in the small intestine even in the - The exact bleeding source may be difficult to identify
absence of ongoing bleeding. - Only 3% - 15% of individuals experience any bleeding (Sabiston, 20th
For persistent mild bleeding from an obscure GI source, push and capsule ed.)
enteroscopy can be used. If these examinations are nondiagnostic, then - 80% of patients, bleeding stops spontaneously
99m Tc-labeled RBC scanning should be performed and, if positive, o 10% will rebleed in 1 yr (Sabiston)
followed by angiography to localize the source of bleeding. 99m Tc- o 50% will rebleed in 10 yrs (Sabiston)
pertechnetate scintigraphy to diagnose Meckel’s diverticulum should be - Symptomatic diverticula
considered, although its yield in patients older than 40 years of age is
extremely low. Patients who remain undiagnosed but continue to bleed and Management:
those with recurrent episodic bleeding significant enough to require blood - Resuscitation
transfusions should then undergo exploration with intraoperative - Localization of bleeding:
enteroscopy. o Colonoscopy - may occasionally identify a bleeding
Patients with persistent severe bleeding from an obscure source should diverticulum that may then be treated with
undergo angiography to help localize the bleeding source. Therapy can be epinephrine injection or cautery.
tailored based on the source. Push enter- oscopy can also be attempted, o Angiography - may be diagnostic and therapeutic
but capsule enteroscopy is too slow to be applicable in this setting. If these o Endoscopic clips
examinations fail to localize the source of bleeding, exploratory
laparoscopy or laparotomy with intraoperative enteroscopy is indicated.
Intra- operative enteroscopy can be done during either laparotomy or
laparoscopy. An endoscope (usually a colonoscope) is inserted into the
small bowel through peroral intubation or through an enterotomy made in
the small bowel or cecum. The endoscope is advanced by successively
telescoping short segments of intes- tine onto the end to the instrument. In
addition to the endoscopic image, the transilluminated bowel should be
examined externally with the operating room lights dimmed, as this
maneuver may facilitate the identification of angiodysplasias. Identified
lesions should be marked with a suture placed on the serosal surface of the § Giant Colonic Diverticulum
bowel; these lesions can be resected after completion of endoscopy. - Extremely RARE
Examination should be performed during instrument insertion rather than - Most occur on: Anti mesenteric side of the sigmoid colon
withdrawal because instrument- induced mucosal trauma can be confused - Asymptomatic or may present with vague abdominal complaints
with angiodysplasias. such as pain, nausea, or constipation
- Barium enema usually diagnostic
o Plain radiographs may suggest the diagnosis
- Resection of the involved colon and diverticulum is
recommended
- Complications: Perforation, volvulus, obstruction

§ Right Sided Diverticula

- Less common
- Occur more often in younger patients than do left-sided
diverticula and are more common in people of Asian descent
than in other populations
- Most patients with right-sided diverticula are asymptomatic
- May mimic acute appendicitis
o Diagnosis of right-sided diverticulitis is subsequently
made in the operating room
- Diverticulectomy may be done (If there is a single large
diverticu- lum and minimal inflammation) but ileocecal
resection is preferred
- Hemorrhage rarely occurs and should be treated in the same
fashion as hemorrhage from a left-sided diverticulum.

Sources:
- 2021 PPT
- Schwartzs Principles of Surgery, 10th Ed
- Sabiston textbook of Surgery 20th ed.
- Kimi ledda trans <3
Sabiston 20th ed.

RBC SCINTIGRAPHY

- The bleeding site is in the descending colon.

6⏐6
liv