noon conference for intern Facebook: Happy Friday Knight

1. VARICEAL BLEEDING AND
MASSIVE UPPER GI BLEEDING:
SURGEON’S ROLE
FACEBOOK: HAPPY FRIDAY KNIGHT
NOON CONFERENCE FOR INTERNS

2. VARICEAL UPPER GASTROINTESTINAL
BLEEDING

3. GASTROESOPHAGEAL VARICEAL BLEEDING
(GEVB)
• Portal hypertensive upper GI bleeding in patients with cirrhosis
• Portal hypertension is initial and main consequences of
cirrhosis
• Cirrhosis: diagnosed by:
• Radiological: US, CT, MRI
• Pathological: liver biopsy (gold standard)

4. https://www.otsuka.co.jp/en/health-and-illness/liver-cirrhosis-nutritional-therapy/early-detection/

7. PORTAL HYPERTENSION: DIAGNOSIS
• Invasive test:
• Hepatic venous pressure gradient (HVPG) ≥ 5 mmHG
• Endoscopy: presents of GEV (portosystemic collaterals)
• Non-invasive test: platelet count < 100,000

8. F
https://my.clevelandclinic.org/health/diseases/1
5429-esophageal-varices
https://upload.wikimedia.org/wikipedia/comm
ons/b/b6/Esophageal_varices_-_wale.jpg

9. WHEN CIRRHOTIC PATIENTS REQUIRE EGD?
• Expert opinion: EGD can be avoided in patients with
• Liver stiffness < 20 kPa
• Plt cont > 150,000/mm2
• Patients whom do not meet these criteria: EGD for GEV screening is
recommended
• Frequency:
• Q2yrs in ongoing liver injury (active alcoholic drinking)
• Q2yrs in presence of small varices
• Q3yrs in absence of ongoing injury

11. • https://www.youtube.com/watch?v=vE0v24-
zm4M&has_verified=1

12. PATIENTS WITH UGIB…
• Airway protection and resuscitation
• Define as EV or non-EV bleeding
• Mortality 20 – 80%
• Imaging study for ruling out HCC with portal vein thrombosis
• immediate goal of therapy in these patients is to
• control bleeding
• prevent early recurrence (within 5 days)
• prevent 6-week mortality

13. VARICEAL HEMORRHAGE MANAGEMENT
• Restrict PRC transfusion (threshold of Hb 7 g/dL and maintain Hb 7 –
9 g/dL)
• Correction of coagulopathy:
• NOT recommend to correct INR by FFP or FVII
• No recommendation for platelet transfusion
• High risk for bacterial infection: antibiotic prophylaxis by ceftriaxone
1 g IV q24h, maximum 7 days (discontinue when UGIB resolved and
vasoactive drug discontinued)
• Vasoactive drugs: somatostatin, octreotide, terlipressin show benefit

15. • EGD ASAP (within 12 hours)  if varices present  EVL
• Injection sclerotherapy for gastric varices
VARICEAL HEMORRHAGE MANAGEMENT

17. WHAT ABOUT SENGSTAKEN BLAKEMORE
TUBE
• Control bleeding by tamponade
effect
• Indications
• Active VH with fail med
• Active VH with EGD/vasoconstrictor
unavailable
• contraindications
• VH slow down
• Recent EGJ surgery
• Known esophageal stricture

18. SENGSTAKEN BLAKEMORE TUBE
PLACEMENT
• ETT intubation first
• Inflate GASTRIC balloon 50 ml  Xray  inflate balloon up to
250 ml
• 1-kg traction
• Inflate ESOPHAGEAL balloon < 45 mmHg only when failed
gastric balloon
• Complication: esophageal or gastric rupture

19. • https://www.youtube.com/watch?v=NHelCd5Jtp4

20. SURGICAL MANAGEMENT IN
NON-VARICEAL HEMORRHAGE

21. TREATMENT MODALITIES FOR BLEEDING
PEPTIC ULCER: ENDOSCOPIC TREATMENT
ADRENALINE
INJECTION HEAT PROBE

22. MASSIVE UGIB
• Hemodynamically unstable
• Require PRC > 4 U in 24 hr

23. TREATMENT MODALITIES FOR BLEEDING
PEPTIC ULCER: ENDOSCOPIC TREATMENT
HEMOCLIP

24. INDICATIONS FOR SURGERY
• Uncontrolled bleeding by endoscopy
• Rebleeding after repeated endoscopic treatment

25. FORREST CLASSIFICATION: ENDOSCOPIC
FINDING
Forrest
classificatio
n
Endoscopic finding Incidence (%) Rebleed without Rx
(%)
Rebleed after Rx (%)
IA Spurting (active bleed) 12 55 15-30
IB Oozing (active bleed) 14 55 15-30
IIA Non-bleeding visible vessel
(recent bleed)
22 43 5
IIB Adherent clot (recent
bleed)
10 22
IIC Flat pigmented spot (recent
bleed)
10 10
III Clean base ulcer (no active
bleed)
32 5

30. TAKE HOME MESSAGE…
• When an UGIB patients come to ER  look for emergency
condition
• Define EV or non-EV
• Cause of bleeding can be from oral to ligament of Treitz
• EV: only medical and endoscopic
• Non-EV: medical  endoscopic  surgical

31. REFERENCES
Garsia-Tsao G, et al. Portal Hypertensive Bleeding in Cirrhosis: Risk
Stratification, Diagnosis, and Management: 2016 Practice Guidance by the
American Association for the Study of Liver Diseases. Hepatol.
2017:65(1);310-335.
Procopet B and Berzigotti A. Diagnosis of cirrhosis and portal hypertension:
imaging, non-invasive markers of fibrosis and liver biopsy. Gastroenterology
report. 2017:5(2); 79-89.
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015.